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Note:

Throughout the document ***** denotes where content was redacted as per the Access to Information Act (R.S.C., 1985, c. A-1) and Privacy Act (R.S.C., 1985, c. P-21).

Some photos have also been removed for copyright reasons.

Due to the content redactions and removal of photos, the report was re-formatted and therefore differs from the original version submitted to the RCMP.

Introduction

The evening of Wednesday, June 4, 2014 in Moncton, New Brunswick was warm and sunny. Children were playing in their yards and on the streets, families were preparing dinner and people were traveling about in their vehicles. No one could have predicted that this bright summer's evening would quickly darken as the tragic events that unfolded would change the lives of many forever.

That evening, within 20 minutes, Constables David Ross, Fabrice Gevaudan, and Douglas Larche were murdered, Constables Eric Dubois and Darlene Goguen were wounded, Cst. Martine Benoit survived multiple rounds fired into her police vehicle and several others were exposed to high powered rifle fire. The unthinkable actions of one individual left three families without their husband, son, father, and brother. The Royal Canadian Mounted Police (RCMP) lost three of their own and the community of Moncton and surrounding areas were stripped of their sense of security. People across New Brunswick and the country were shaken to their core as they tried to make sense of such a senseless tragedy.

On June 25, 2014, RCMP Commissioner, Bob Paulson sent a message to all RCMP employees stating, "the death of our three members in the course of duty and the near deaths of many others demand that we seek to fully understand the facts, learn from them and, if required, change our practices promptly."

On June 30, 2014, the Commissioner appointed Assistant Commissioner Alphonse MacNeil (ret'd) as the Reviewer to undertake an independent review of the circumstances surrounding the shootings. The Commissioner granted a 90 day timeframe to submit a report and identified 13 areas which he wanted reviewed and applicable recommendations made.

As Reviewer, I assembled a team to assist in this fact-finding mission and address the 13 areas highlighted by the Commissioner. The team was comprised of RCMP employees from across Canada who have expertise in a multitude of disciplines. In addition, the team received assistance from a number of contributors who are subject matter experts in their respective areas. Our goal from the beginning was to learn from this tragedy so that members in the future, who perform their duty at enormous personal risk, will have the best training, tools and operating procedures the RCMP can provide.

Reviews of this nature involve much more than simply conducting an investigation and writing a report. The team conducted a thorough and detailed review but never once lost sight of the fact that members of the Force were killed and injured and many others were impacted in ways that most of us will never understand.

We have met with families of the fallen and have collectively spoken with hundreds of people including the members who were present while shots were being fired and many others who responded in the following days. We have talked with civilian witnesses and walked their neighbourhoods countless times to piece together what took place. For those we spoke with, this process was not easy. Wounds were fresh, healing had just begun and people were only beginning to pick up the pieces and move forward. The willingness of the people of Moncton to speak with us and provide information despite their painful memories was remarkable and something we will not soon forget.

With this Review there were anticipated and unforeseen challenges. The duration for the Review (90 days) was driven by a need to identify any shortcomings as soon as possible in an effort to mitigate the risk to other members of the Force, however, the time allotted did limit the depths to which some issues could be explored. Nevertheless, we are confident that we had the time, the resources and the independence required to assess the 13 areas within the Review's mandate to identify key issues and suggest improvements.

To conduct the Review, the team had to first establish exactly what occurred on June 4, 2014, and the days that followed. To accomplish this we studied pertinent aspects of the Major Crimes investigation and in addition reviewed OCC transmissions, member-to-member radio and telephone communication, 911 calls, video footage, civilian and member statements as well as forensic evidence. The team also re-interviewed multiple members and civilians and attended the scenes with members who were directly involved to obtain first-hand accounts. The information we relied on to understand what took place was largely dependent upon the memories of those involved, including both citizens and police. Following a traumatic event, memories are affected by the trauma, time, subsequent discussions with others and exposure to media, photographs and video. There is an abundance of psychological literature and scientific research on the fallibility of memory in high-stress situations and this supports what we have seen in our Review. Current literature indicates that perceptions are often not the same for officers involved in the same incident. Distortions can include tunnel vision and memory loss for parts of the event. It is natural for officers involved in a traumatic event to not recall or have inaccurate recollections of what took place.

As a result of this, the positions of some individuals at key points during the incident are approximations based on the totality of the information available to the Review Team. It is expected that those who read this report who were involved in this incident may experience further evolution of their recollections as they process the information contained herein.

Although we analyzed the statement of Justin Bourque, the fact that he was still engaged in the judicial process precluded me from interviewing him. This limited our ability to ask him key questions that could have provided greater insight into his actions and his background. It would be beneficial to interview Justin Bourque to determine what motivated him and to gain insight into how this tragedy could have been prevented.

This report opens with a narrative description of what happened from the first 911 call until the subject of concern is arrested 29 hours later. We then examine the 13 questions in the order presented by the Commissioner: Tactics and Response to the Initial Call, Decision Making and Risk Assessment to the Initial Call, Supervision, Evolving Response, Equipment and Weapons, Member Training and Officer Safety Skills, Operational Communications, Communications and Media, Broader Policy Review, Firearms Possession by Accused, Perpetrator Information/Intelligence, Aftercare of Employees and Implementation of Mayerthorpe Recommendations.

I would like to take this opportunity to recognize the exceptional work of the team assembled to conduct this Review. They worked long hours with limited time off to produce a product they are deeply invested in. They were exposed to every detail of this horrific incident and will carry the related impact of that exposure. As RCMP employees, they feel this tragedy in a way that motivated them throughout the Review.

It is my hope that the recommendations I put forward in this report will contribute to the safety of the membership and enhance the quality of service that supports all RCMP employees and family members.

I want to acknowledge the extreme bravery of those who gave and risked their lives to protect others within the community of Moncton and above all else pass on to the families of those who lost their lives our sincerest sympathy.

Narrative Description June 4, 19:18 to June 6, 00:20

Initial Response to the 911 Call

At 19:18 the Operational Communication Centre (OCC) in Moncton received a 911 call reporting a subject of concern (SOC): a male wearing camouflaged clothing walking down the middle of the road towards the woods on Pioneer Avenue, carrying two long guns and bullets. He proceeded into the woods at the western end of Pioneer. The first caller stated she did not see his face but he appeared to have something on his mind; he appeared to be on a mission. Another caller stated that the SOC's expression made her believe he was a threat.

This call was dispatched at 19:20 to Cst. Jay Doiron, with Cst. Mathieu Daigle and Cst. Shelly Mitchell as backup. Cst. Eric Dubois responded as backup as well. As the call was being dispatched Cst. Rob Nickerson, Cst. Fabrice Gevaudan, Cst. Andrew Johnstone, Cst. Eric White and the acting Sgt., Cpl. Jacques Cloutier, were finishing a briefing at the Codiac detachment. Codiac members have subsequently told the Review that a call of a suspicious male with a firearm was common in Moncton. In this case, however, there were multiple calls about this individual, including descriptions of the suspect's demeanour. Cst. Nickerson, Cst. Gevaudan, Cst. Johnstone and Cst. White all responded to assist in setting up a perimeter (Nickerson was initially asked to patrol the area). Cpl. Peter MacLean and Cst. Michel Martel partnered up and also responded, with Cst. Martel signing out a shotgun before departing. Cst. Dave Verret ***** when he heard numerous members being dispatched to this call. He went back on the road and took up a perimeter position as directed by the OCC.

The Perimeter Set-up

Cst. Doiron went to Pioneer Avenue in search of more information about the SOC and spoke to a complainant who was outside and still on the 911 call. He obtained additional information on the suspect's direction of travel and demeanour. He parked at the west end of Pioneer (a dead end) where the suspect was last seen and, with his pistol drawn, walked through the wooded area to a relatively narrow clearing. This clearing consisted of a dirt path that extends from the barricaded end of Mailhot Avenue. The SOC appeared to have taken a path into the wooded area on the western side of the clearing. After following for a few metres, Doiron reassessed the risk, returned to the clearing and took cover behind a telephone pole. That section of woods is very dense with poor visibility, so much so that a camouflaged person 20m away could easily hide from view. Doiron held his position and requested a perimeter be established on the residential streets around the woods and that additional back up and Police Dog Services (PDS) be dispatched.

Initial perimeter positions of all officers responding to the initial complaint. Bourque's path is the red line.

Cst. Eric Dubois attended Pioneer Avenue as back up for Cst. Doiron. Cst. Daigle was dispatched to the Rennick Road/Shannon Drive area which is where the SOC would appear if he maintained course. Daigle exited his vehicle and positioned himself at a fence behind an apartment building at 185 Rennick Road. Other officers were responding to the call and approaching from this direction as well. Cst. Mitchell had originally gone to Lonsdale Drive, but then made her way to the Shannon/Rennick area, as did Cst. Gevaudan. Cst. Nickerson was still patrolling the area at this time. Cpl. James MacPherson was working in plain clothes on a major crimes investigation and heard this situation developing on the radio. Knowing the area well, he informed members that the wooded area off Bromfield Court comes out on Willshire Way.

Cst. Johnstone drove to the end of Mailhot where he could see Cst. Doiron. Doiron requested an ETA for PDS and was subsequently informed by Cpl. Cloutier, by phone, that PDS would be delayed. Johnstone teamed up with Doiron.

Cpl. MacLean directed the OCC to have someone speak to the witness to get the best possible description in an effort to try to identify the suspect. Cst. Dubois took on this task and repositioned to the end of Pioneer. Cst. Dave Verret was directed by the OCC to position on Lonsdale Drive to the north of the wooded area. Cpl. MacLean and Cst. Martel were approaching the area in the same vehicle. Cst. Eric White was en route. As numerous members approached with sirens on, the SOC would have known that police were closing in.

Establishing Contact with the Subject of Concern

Cst. Daigle heard cracking coming from the woods and observed the SOC, carrying something, come out of the woods on the north side of Bromfield Court and quickly cross to the woods on the south side of the Court. Daigle later stated the suspect was walking in a stealthy manner, as though he was hunting (stopping, listening, etc.).

Cst. Daigle broadcast that he saw the suspect walking near a new housing development and he appeared to be carrying something (Daigle did not know the street name but the OCC confirms it is Bromfield Court). He then stated on air that he saw the suspect cross the street and enter a wooded area walking in the direction of Ryan Street. This is the wooded area which borders the backyards of residences on Bromfield, Mailhot, Bellerose Court and Willshire Way. At this point, Cst. Daigle attempted to close the distance with the suspect while maintaining visual contact. It did not appear that the SOC had seen Cst. Daigle.

After speaking with witnesses on Pioneer Avenue, Cst. Eric Dubois broadcast a confirmation of the SOC's description: "male, late 20s, camouflaged all over, a brown headband, shoulder long brown hair, he has a bow on his back, maybe two rifles, a knife on one leg, and he was really bizarre to everyone, walking straight, possibly under the influence of something." Some radio static was heard as the SOC's demeanor was being described and this made it difficult to understand what was being said.

After Cst. Daigle broadcast his latest sighting of the suspect, members began to adjust the perimeter accordingly. It is important to remember that this incident occurred early on a warm, sunny Wednesday evening and that, after a string of rainy days, many residents were outside taking advantage of the pleasant weather. Cst. Gevaudan, Cst. Mitchell and Cst. Nickerson parked their vehicles in the vicinity of the apartment building at 185 Rennick Road and proceeded on foot to Bromfield to back up Cst. Daigle. They spoke briefly with him near where the suspect had last entered the woods. After observing children playing in the backyards on Willshire, Csts. Nickerson and Mitchell went to direct them to go into their homes. Residents located in their backyard about 45m south of the SOC could hear police shouting for people to get in their homes.

Csts. Daigle and Gevaudan continued along the treeline of the wooded area on the south side of Bromfield toward Mailhot, trying to see the suspect. They made their way into the woods beside 15 Bromfield just to the south of the home. At this point, Cst. Nickerson was returning from Willshire through the woods and was the next closest member to Daigle and Gevaudan. They can be heard on the radio communicating each other's relative positions as they closed in on the SOC.

At about the same time, Cst. White, Cst. Martel (armed with a shotgun) and Cpl. MacLean were approaching Willshire Way (by car). Cst. Mitchell was also making her way back from the direction of Willshire Way. Cst. Doiron, whose vehicle was still on Pioneer, got in with Cst. Johnstone and they drove to Bromfield, parking in the driveway across the street from 15 Bromfield. In total, there were eight members in or approaching the small wooded area. The members were now within 100m of the SOC, attempting to regain visual contact and awaiting the arrival of Police Dog Services. They repeatedly asked about details on the dog handler's arrival. It is during this approach that they were informed by Cpl. Cloutier that "it is going to be a few minutes" before the dog handler, Cst. Ross is mobile.

Cst. Daigle saw the SOC in the woods behind 15 Bromfield and radioed that the SOC was walking away from him. This meant that the SOC was about to leave the woods and enter a backyard. PHOTO

Cst. Gevaudan and Daigle conferred briefly, after which Cst. Gevaudan moved around the back of 15 Bromfield to within 30m of the SOC while Daigle moved around the front of the house towards its far side, based on eyewitnesses and physical evidence. Cst. Gevaudan had his pistol drawn and was pointing in the vicinity of the SOC. Cst. Gevaudan was partially concealed from the SOC by trees, but these trees afforded minimal cover. Cpl. MacLean and Cst. Martel, travelling in the same vehicle, broadcast their arrival at Willshire Way just as Cst. Gevaudan directs members to, "clear the air."

In his statement the SOC said he heard someone yell "hey!" He turned, saw a police officer and fired three quick shots; his bullets struck small trees about 5m in front of Gevaudan, before striking the residence behind Gevaudan. The SOC did not appear to notice any police officer but Gevaudan. At this point Cst. Daigle was just reaching the north corner of the house

A split view of the backyard where Cst. Gevaudan was shot. The first is Cst. Gevaudan's view of the shooter's position. The second is near the shooter's view of Cst. Gevaudan's position.

After the first shots were fired, Cst. Gevaudan ran northeast. Gevaudan radioed, "he's shooting at me, he's shooting at me". The gunman fired two more shots: one had an unimpeded trajectory and the other skimmed along the side of a birch tree. Both bullets hit Cst. Gevaudan in the side of the torso from a distance of about 30m and produced wounds which were almost instantly fatal. Cst. Nickerson who had just joined Daigle at the house saw Cst. Gevaudan run behind the back of 19 Bromfield and drop from sight after the last shot but could not see the shooter. The time was 19:47.

Suspect Evades Containment & Shoots Constable Dave Ross

Once the first, very loud shots were fired, everyone's focus was on tactically repositioning, most did so around the front and side of 15 Bromfield. It wasn't clear that Cst. Gevaudan had been shot. From the road a member caught a glimpse of the gunman fleeing the scene of the shooting, passing through backyards on Mailhot. The gunman emerged just southeast of McCoy Street.

To get a better sense of the neighbourhood and the relative locations of houses, several features are noteworthy. Most of the houses do not have fences so it is easy to cross yards quickly. There are trees, landscaping features and sheds in many backyards, so while there is a sense of openness, many sightlines are interrupted. Some of the key sightlines referenced in this report no longer exist as some fences have since been built and vegetation has grown. The street numbering in much of this area increases by increments of six (e.g. 166 Mailhot is next door to 172 Mailhot) but on Bromfield 15 is next door to 19.

At this time, Cst. Dave Ross was rapidly approaching 15 Bromfield *****. His situational awareness may have been limited to his brief telephone conversation with Cpl. Cloutier and the OCC before any shots had been fired. He may have heard the broadcast, "shots fired" and "he is shooting at me," However, he would not have known a member had actually been shot. He turned his vehicle right off McCoy onto Mailhot toward Bromfield. Cst. Johnstone, who had moved to the corner of Mailhot and Bromfield, directed Ross to turn around. Cst. Ross completed a U-turn and stated over the air, "got a visual, will be on takedown in a second." At this point, the suspect was calmly walking away (southeast) down Mailhot moving his rifle from one hand to the other. Ross accelerated quickly towards the gunman who was at this point across the street from two civilians in a vehicle that had come to a stop. The gunman turned around to face Ross' oncoming police vehicle.

Cst. Ross turned on his lights and drew his pistol as he rapidly closed in on the gunman. Ross fired two rounds through the windshield towards the shooter. There is a photo widely circulated in the media showing a very close grouping of three rounds in the police vehicle windshield. Two of those rounds were from Cst. Dave Ross's handgun, and only one round was from the weapon of the gunman.

Cst. Ross' windshield with Bourque's shots in red and Cst. Ross' in blue.

It is possible that Ross was trying to hit the shooter with his vehicle (the throttle control sensor and fuel line in the police car were hit with one of the first rifle shots, causing a loss of propulsion). Six rounds were fired at Ross, beginning while his vehicle was approaching and continuing as the vehicle rolled a short distance past the shooter. Cst. Ross was struck by bullets to the thumb of his gun hand, his head and his left shoulder area. The head wound killed him instantly. The time was 19:49:51.

Between the time of the first shots at Cst. Gevaudan and the shooting of Cst. Ross, members took cover at the front of 15 Bromfield. Members moved through the front yard in the direction of Mailhot while others took up positions at the northeastern corner of the house, beside a small basketball court on the property. Cst. Daigle can be heard attempting to communicate with Cst. Gevaudan by radio. Members had yet to see Cst. Gevaudan's body before Cst. Ross was under fire. The time between the murders of Cst. Gevaudan and Cst. Ross was just two minutes.

Cpl. MacLean walked across the basketball court until he saw Cst. Gevaudan lying face down behind the backyard of 19 Bromfield. He went to Gevaudan, rolled him over and saw two visible gunshot wounds. He removed Gevaudan's vest, applied pressure to the wounds and checked for vital signs; believing that he detected a faint pulse but no breathing. He was joined by Cst. Nickerson, who quickly recognized the need to take cover. Cst. Daigle arrived and the three moved Gevaudan to a shallow gully beside a wooden fence for some cover. Cst. Johnstone arrived and Cpl. MacLean instructed the members to do what they could for Gevaudan before he took Gevaudan's radio and left to pursue the gunman. The members took Gevaudan to the front of 19 Bromfield and into the garage.

Cst. White recalled approaching the intersection of Bromfield and Mailhot and observing Cst. Ross do the U-turn on Mailhot. He heard Cst. Ross's PDS vehicle racing down Mailhot and then heard shots just as he was about to round the corner of the home at Bromfield and Mailhot. He saw the PDS vehicle stopped in front of 166 Mailhot, 240m from his location. White ran towards the PDS vehicle, going from house to house for cover. He approached the driver's side window and noted that it was fractured but not broken out. Ross was slumped over, unresponsive, in the driver's seat with visible injuries to his neck and face. Wanting to better assess the condition of Ross, White smashed the window with his hand to unlock the vehicle. He scanned and saw the gunman step onto the street about 100m to the southeast on Mailhot beginning to take aim at him. White sought cover behind Ross' vehicle and observed the gunman go between 143 and 149 Mailhot. This property line leads to a wooded area beside the Hildegard Fire Station. White advised over the radio where he had seen the gunman. He then returned to retrieve Ross and dragged him to a fenced area in the yard beside 166 Mailhot. He quickly realized that Cst. Ross was dead. In response to Cloutier's asking who was injured, White responded with, "Ross is down, Ross is down." White was joined at this location by Cpl. MacLean and Csts. Mitchell, Martel, and Doiron.

Scene of Cst. Ross' shooting on a residential street near a parked SUV and bicycle. Bottom Right inset (redacted photo) – Bourque just before shooting Cst. Ross. The centre bottom inset shows the position of spent casings.

At about this point Cpl. MacLean broadcasts, "get ERT…call ERT, we need everything we've got!"

Shootings on Hildegard

Cst. Martine Benoit and Cst. Nick Gilfillan were in the office after a dayshift and were monitoring the call of a suspicious male on the radio. When it was reported that shots had been fired, Cpl. Cloutier came out of his office and said he needed everyone on the road. Cst. Benoit deployed immediately and Cst. Gilfillan, who had already changed into civilian clothes, went to change back into his uniform before responding. At approximately the same time, Major Crimes Unit members Cpl. MacPherson, Cpl. Jean Belliveau, Cpl. Michel Dupuis and Cst. Doug Larche, who were working in plain clothes on an unrelated investigation, returned to the detachment to obtain shotguns to respond as backup.

Cst. Benoit drove to the area with lights and sirens activated and turned onto Hildegard Drive just as the OCC reported the suspect was at Hildegard and Mailhot. Of note, the OCC had taken a call from a witness who had actually been following the gunman on Hildegard. The witness first observed the gunman laying in the grass near the Hildegard Fire Station aiming his rifle northeast up Hildegard in the direction of Mountain Road. The caller then observed the gunman get up and walk southwest on Hildegard toward the intersection at Mailhot. The gunman went into a slow jog at one point, crossed Mailhot with the civilian following at a distance, and entered the treeline at the bend in Hildegard just west of Mailhot. This call lasted almost three minutes and the information as to where the gunman entered into the woods was dispatched to members. The OCC operator informed the witness that a police car should be approaching his location. The caller stated he could see the police vehicle and the call with the OCC ended. The time was 19:54 hours.

Cst. Benoit was flagged down by several civilians at Hildegard and Mailhot and they pointed to where the gunman entered the woods. She parked her vehicle at the intersection and started opening her door but did not exit the vehicle. She was assessing the situation when she began to take fire. She ducked down to use the engine block as cover and tried to reverse her vehicle, but it wouldn't move as it had been disabled by the gunfire. Cst. Benoit radioed that she was being shot at and the shots were coming from in front of her vehicle. Cst. Benoit was never able to see the shooter. Witnesses later stated the police officer couldn't see the shooter because he was ducking down and would only pop his head up every few seconds, from a deeply shaded and wooded ditch. Cst. Benoit also advised over the radio that her car was disabled. On several occasions, Cst. Benoit asked via radio if it was safe to get out of her car and requested assistance.

Cst. Eric Dubois, who left Bromfield Court to retrieve his vehicle from Pioneer Avenue, was now stationed at Hildegard and Mountain to block traffic. On hearing Cst. Benoit's request for assistance, he drove to her location and positioned his vehicle next to Cst. Benoit's where he felt it would provide additional cover from the shooter. He told Cst. Benoit to reposition behind his vehicle. The gunman fired several more shots at them and Cst. Dubois was injured while trying to spot the shooter's position. Cst. Dubois ran to the fire station after observing the gunman cross Hildegard. Cst. Benoit, not knowing the gunman had left, decided to remain behind cover and called for someone to get her. Cst. Nick Gilfillan, who had just arrived at the fire station, drove to her location. She got into his car and they returned to the fire station.

Both Cst. Benoit and Cst. Dubois mention lulls in the shooting. A media photographer took several photos of Benoit and Dubois behind Dubois' vehicle (see below), with civilian traffic in the background. He was unknowingly taking these photos from a location on Hildegard just northeast of and across the street from the shooter.

Redacted map and photo depicting shots fired at ***** can be observed behind the police vehicle.

Cst. Goguen was working in the Southeast District, which borders on the Codiac detachment area. Southeast District uses a different radio frequency and is dispatched through the OCC at "J" Division Headquarters in Fredericton. Members are able to use ***** which allows them to hear radio broadcasts from other channels but these are overridden by any simultaneous broadcasts on their own channel. Cst. Goguen learned about the situation unfolding in Codiac *****.

She subsequently phoned her supervisor, Cst. Donnie Robertson and while speaking to Cst. Robertson, he turned on his radio ***** and heard Cst. Benoit on the radio saying she was under fire. Cst. Goguen then heard Sgt. Andre Pepin requesting backup be provided by Southeast cars close to Hildegard. Cst. Goguen replied she was close and was instructed to go to the Hildegard Fire Station. She encountered several civilian vehicles doing U-turns on Hildegard and then heard gunshots nearby. Cst. Goguen was turning her car around when she heard more shots and the front passenger window was shot out of her vehicle and two rounds hit the passenger door above the door handle. As she drove away, another shot broke her driver's window. Six bullets struck Cst. Goguen's car with at least four of them coming extremely close to or striking her. After the last round was fired at Cst. Goguen, the shot was fired that wounded Cst. Dubois.

The Complexity of the Situation – Multiple Events Unfolding

As Cst. Goguen was operating on a different channel and the OCC in Codiac was not aware she was attending the scene, there was confusion as to how many members were shot, the location of the shootings, where the suspect was and where ambulances were needed. There were two erroneous reports broadcast about shots fired on Lonsdale and the gunman being at the 'corner of Lonsdale and Mailhot' (this is not an actual civic location) as well as a report of him being on Foxwood Drive moving towards Ryan when he had in fact already crossed Hildegard and was heading towards Mailhot. Cst. Goguen had eventually driven to Penrose Street after being assisted by Cst. Robertson. He and Cst. Ugo Desjardins, also from Southeast District, provided protection for her and requested an ambulance. At this time, the members tending to Cst. Gevaudan were waiting for an ambulance at 15 Bromfield.

The location of Bourque as he fired upon Cst. Benoit, Cst. Goguen and Cst. Dubois. Glass is depicted where Cst. Goguen's window was hit. The inset to the bottom right is a redacted photo of Cst. Goguen's vehicle driving off, after shots impacted. The redacted photo to the bottom left is Bourque walking away from this shooting scene.

There was also confusion as to the condition of Cst. Ross, and thus it was believed an ambulance was needed at 166 Mailhot. In addition, Cst. Dubois had requested an ambulance at the fire station and now Goguen's colleagues were requesting an ambulance at Penrose. As per their policy, no ambulance can enter the area of an active shooting. Goguen was eventually transported to the hospital by her colleagues who realized the ambulance was not coming. Cst. Dubois was transported to hospital by Cst. Mitchell in a car she had commandeered from a civilian.

Hildegard Fire Station

The fire station parking lot became a staging area for police just out of the line of fire on Hildegard. Cpl. Lisa Whittington had just started her shift as the night shift supervisor at 19:00, responding from the office after Cpl. Cloutier requested she assist Cpl. MacLean in supervising at the scene. Also at the fire station were Csts. Doiron, Gilfillan, Martel, Benoit, Verret and Johnstone. After transporting Cst. Goguen to the hospital, Csts. Robertson and Desjardins also returned to the fire station. Civilian traffic, both on foot and in vehicles, in the area of the shooting was steady throughout the incident. Due to the fact that the gunman had ample opportunity to shoot multiple civilians, members began to make the assumption that the gunman was targeting only police officers. Due to this, members took cover at the fire hall.

Video footage of the fire station scene during this time captures the sound of gunfire from the shootout between Cst. Larche and the gunman. It is broadcast that a civilian is down on Isington (this in fact was Cst. Larche who was not in uniform). Constables Doiron, Gilfillan, Martel and Verret determined that this was a "game-changer" and began moving toward Isington. Gilfillan put on his HBA and instructs other members to do the same. They begin moving as a team down Mailhot toward Isington.

Shooting of Constable Doug Larche

Cst. Doug Larche, one of the plain clothes MCU members who returned to the detachment to retrieve a shotgun before attending the scene, pulled up to the stop sign at Isington at the corner of Mailhot facing west. He radioed to the OCC that he was going to be out on foot at Isington and Mailhot and got out with a shotgun. Cst. Larche did not mention seeing the gunman. The gunman was seen (by a civilian) walking down Mailhot toward Larche's position and, upon seeing Larche, he stepped into the trees beside 71 Isington (the house on the corner of Isington and Mailhot). When he recognized Larche was a police officer because he was wearing soft body armour (SBA), he fired four rounds at him from the concealed position within the trees at the west side of the house. Larche was wounded by rifle rounds passing through his vehicle and dropped to the ground. The gunman went behind 71 Isington and came out on the opposite side of the house. Larche somehow found the strength to get back up and fire his weapon but was ultimately killed by a shot to the head from gunfire from the east side of 71 Isington. It is known that Larche fired a total of seven shots from his service pistol during this 70 second exchange of gunfire. The time was 20:07.

Cst. White heard a call that there was an officer down at 16 Mailhot Avenue. He was already heading in that direction so he kept going on foot from backyard to backyard. He came around a house and saw Cst. Larche's shot-up vehicle and several civilians standing around the scene. One of the civilians pointed down Isington Street and said the gunman had been standing there five minutes ago but had run behind the houses. Cst. White and a civilian moved Cst. Larche's body inside 71 Isington. Cst. White called in his location as well as the status of Cst. Larche. When civilians began to gather around Larche's vehicle again, White went outside and retrieved Larche's pistol, shotgun and radio from the ground.

The period of time between the shooting of Csts. Fabrice Gevaudan, Dave Ross and Doug Larche was a total of twenty minutes.

Map view of Isington Street and Mailhot Aveue depicting Cst. Larche's position and Bourque's location and path around the residence. Photo insets, bottom left depict the first location where Bourque shot Cst. Larche in the backyard of a residence. Bottom right depicts Cst. Larche's vehicle.

The gunman was observed after the final shooting fleeing into the woods behind Isington Avenue, and crossing into the woods south of Ryan Street. This was the last time the shooter was seen for the next several hours. After the gunman entered the woods, members held their positions and did not pursue the suspect further.

Post Shooting Manhunt

The description of this portion of the manhunt phase of the incident will be less detailed than the account of the shootings. The following provides a broad sense of who was in charge at key points during the manhunt, how command structures were established, what actions were taken as resources were mobilized and the arrest of the suspect.

Initially, Cpl. Jacques Cloutier, the acting Sgt. was in command from his office at Codiac detachment, which became the centre of operations. While Cloutier was extremely busy calling-in and deploying resources for containment, members at the scenes were largely left to manage on their own. Within half an hour of the first shots, commissioned officers and senior NCOs began to gather at the Codiac detachment. The command structure became less clear to some staff with the arrival of the Codiac Operations Officer, Insp. David Vautour at 20:20. Both continued managing different aspects of the incident from the same office. Insp. Vautour became the Incident Commander at that point, a scribe was appointed and staff were given specific tasks. First responders on the ground were not made aware of the command structure. Both Cloutier and Vautour were extremely busy and the situation in Codiac detachment was hectic. Information was coming in by telephone, radio, CIIDS, direct reports from members in person, and media reports. *****. Supt. Tom Critchlow, a Critical Incident Commander (CIC) arrived at Codiac detachment, *****. He assisted Insp. Vautour and Cpl. Cloutier, *****

No broadcast was made by a commander regarding the specific threat presented to members although members were becoming aware through word of mouth. Some on scene members did not know the full extent of casualties until many hours later. The last known location of the suspect near Ryan Street and Wheeler Boulevard, was attended by many members who were on foot or sitting in marked police vehicles.

Without knowledge of the location of the suspect, they were later determined to have been in a very vulnerable position.

The first two "J" Division Emergency Response Team (ERT) members to arrive on scene linked up with a Police Dog Service member who believed his dog had identified a starting point from which to track the suspect into the wooded area between Ryan Street and Highway 15. When two more ERT members arrived, the PDS member began tracking into the woods with the four ERT members in support. When the team leader, who was still driving to Moncton, was informed of this pursuit he ordered them to stop as it was nearly dark and the risk of ambush was too high.

At this time, which was still within an hour of the last shots being fired, police from other districts and detachments, municipal agencies and "H" Division members poured into Moncton in response to Codiac's requests for resources. No mechanism to track and coordinate these resources was in place and members began arriving in the Moncton area without direction on where to go or what to do. *****.

Throughout the evening, members were responding to unconfirmed sightings of the gunman that were broadcast via radio without sufficient information and tactical awareness. In addition they did not maintain set positions within the semi-established and loosely held perimeter. Many members took positions and responded to broadcasted information without informing anyone in charge or seeking clarity on who was in charge. The OCC and others were assigning members to general perimeter locations, however, members were not told to report their positions. No one at the Codiac detachment was keeping track of these locations, members' identities, additional weaponry on site or the duration of the shifts members were working. Members who were interviewed by the Review Team described this period of time as chaotic and disorganized.

Map depicting 'lock-down' area. The red lines depicts Bourque's known movements and the red circle 'B' is his arrest location.

Shortly after 21:15, pictures of the gunman walking away from the scene of the shootings on Hildegard appeared in news reports and social media. The photo-journalist who had witnessed the shooting of Cst. Goguen took the pictures with a telephoto lens shortly after that shooting. Family and friends of the gunman quickly called 911 and identified him as Justin Bourque, a 24 year-old Moncton resident who lived at 13 Pioneer Avenue. *****.

The Moncton Coliseum (a building with large parking lots about two kilometers from the scene) was initially identified by staff at Codiac detachment as a command post location and arriving members were directed there. Inspector Kevin Leahy, the first accredited Critical Incident Commander (CIC) assigned to the incident decided this was a poor location and it was subsequently moved to the Moncton Garrison Canadian Forces Base Gagetown – Detachment Moncton, formerly known as CFB Moncton. Ultimately, this critical incident command post was not operational until approximately 03:00 on June 5.

During the manhunt there was a wide range of concurrent tactical and investigative police activities taking place in what was presumed to be close proximity to a heavily armed police killer. Without knowing Bourque's location it was impossible to have a definitive perimeter and effective containment, thus all policing activities were extremely high- risk. The incident commanders, as well as all deployed responders, were faced with the fact that Bourque had significant tactical advantage, including the ability to fire upon police or anyone else, should he so choose.

In addition to actively searching for Bourque, there were multiple crime scenes to examine as part of the ongoing criminal investigation into the murders and attempted murders. As these scenes were all near the last known location of the gunman, protective perimeters were set up around the investigative personnel at these sites.

Additionally, there was the massive logistical challenge of effectively equipping and deploying hundreds of RCMP members and police officers from different agencies arriving from across Atlantic and Central Canada so that they were operationally ready.

Of the hundreds of police officers arriving in Moncton, there were eventually one hundred Tactical Team members on scene. Three of the four RCMP Atlantic Region Emergency Response Teams, as well as those from "C" and National Divisions, were deployed. The municipal police forces of Bathurst, Miramichi, Fredericton and Saint John also contributed their tactical teams. Providing direct support to these teams were six scribes, four radio technicians, 14 Emergency Medical Response Team (EMRT) members, 11 PDS teams, and EDU & Special "I" personnel. Five RCMP Tactical Armoured Vehicles (TAVs) and aircraft from both RCMP Air Services (including chartered commercial carriers) and Transport Canada provided tactical and logistical support.

From the time Bourque fled into the woods, he was always close to large numbers of officers. Over that 29 hour span, members, including ERT, responded to many reported sightings of the suspect all within a couple kilometers of the last crime scene. Only two of the reported sightings appeared to be accurate. By the time ERT responded to the first apparently legitimate report at Isington, shortly after midnight on June 5, Bourque had once again disappeared. The second verified sighting off Mecca Drive resulted in his arrest.

The Arrest

Late in the evening on June 5, a call was received from the eastern end of Mecca Drive where a resident reported seeing a man crouched outside below the kitchen window, wearing a camouflage jacket and brown pants. The man ran into the wooded area behind the house. ERT members aboard TAV's attended the area and aircraft were deployed *****.

*****.

*****.

*****. He issued an order of, "come out with your hands up!" The suspect replied, "I give up, don't shoot!" He left his firearms behind and came out of his hiding place with his hands up. Members quickly confirmed that they had arrested Justin Bourque.

Daylight Aerial photo of arrest location (red dot, 21 Mecca Dr. at 140606 00:10) and the point was last seen (yellow dot, 31 Isington Ct. at 140605 00:36). Police vehicles (blue rectangles) around the arrest location. Two redacted photos show ERT members approaching to arrest.

Aerial photo and map identifying these locations:

SOC residence.

Cst. Doiron's initial position.

SOC observed by Cst. Daigle

Cst. Daigle first location, follows after SOC.

Csts. Daigle Nickerson, Mitchell meet followed by Gevaudan.

Cst. Daigle and Cst. Gevaudan see SOC behind 15 Bromfield.

SOC escapes, After Cst. Gevaudan shot. Cst. Ross nearing area.

Cst. Ross shot by SOC.

SOC seen by Cst. White, aiming at him.

Witness reporting SOC movement at Fire hall.

Cst. Benoits and Dubois under fire.

SOC's firing position at location K and M.

Cst. Goguen is shot, after Benoit and before Dubois.

Cst. Larch position on foot.

SOC first shoots Cst. Larche from this position and moves around house shooting again.

SOC seen at 00:36 on June 5.

SOC arrested at 00:10 on June 6.

In the mandate letter to the Reviewing Officer, the Commissioner outlined 13 areas to be examined. Each of the areas will be dealt with separately with the exception of number one, Tactics and Response to the initial call and number two, Decision Making and Risk Assessment to the initial call. These will be combined as one section due to the interrelated nature.

Within the report it was necessary to repeat information because of the interrelated nature of the 13 sections. Many of the Sections do not exist in isolation; as such there is overlap and repetition between certain sections.

Section 1: Tactics and Response to the Initial Call

Question from the Commissioner: Does the manner in which the members were dispatched and coordinated in their response to this call suggest any improvements can be made in RCMP training, policy or other areas? Are there recommended improvements to the tactics employed given the facts known at the time?

The Tactical response will be addressed here, however, Training and Policy improvements will be addressed in their respective areas within the 13 sections.

Section 2: Decision Making and Risk Assessment to the Initial Call

Question from the Commissioner: Was there an opportunity to reassess the call and our response as it unfolded in the early moments?

The Incident Management Intervention Model (IMIM)

The IMIM is a visual aid and guideline which is designed to assist an officer in articulating the decision-making process involved in his/her selection of a particular intervention option. The IMIM is neither policy nor law, nor should it be used on its own to justify any actions on the part of the officer. It is important to understand that it is not a step-by-step approach in the development of an articulation of what the officer did. The intervention option chosen by an officer is based on several variables, which are explained below.

The IMIM is designed around 6 basic principles:

The primary duty of an officer is to preserve and protect life;

The primary objective of any intervention is public safety;

Police safety is essential to public safety;

The IMIM is consistent with law and policy, in no way does it augment or replace it;

The IMIM is consistently intertwined with a risk assessment

The risk assessment is continuous and evolves throughout an intervention/situation.

The terminology referring to "least intervention", "least amount of force" or "intervention causing the least harm" has been removed from the Criminal Code as the Courts recognized it to be an unrealistic expectation that could put the safety of the officers in jeopardy. This terminology was replaced by "necessary" and/or "reasonable" amount of force to control the subject/situation.

There is no step-by-step process to assessing the risk as this is done continuously throughout an intervention. The risk assessment will be influenced by the type of event (planned events vs unfolding events vs spontaneous events). The risk assessment formed is based on the four following categories depicted on the IMIM model.

Situational Factors: The situational factors may change throughout an incident and directly impact the officer's risk assessment and include:

Environment: weather if outdoor, lighting conditions, location, the availability of cover or concealment, the presence of bio-hazard, etc.

Number of subjects (vs number of officers);

Perceived Abilities of the Subject: diminished by a form of intoxication, increased by a form of intoxication, size/strength/athletic skills, emotional state;

Time and Distance: presence or not of escape routes (both for officer and the subject); does the situation allow officer to create a reactionary gap (increase time/distance);

Threat Cues: verbal and/or non-verbal;

Knowledge of Subject (including, but not limited to personal previous experience with the subject, known to be armed and dangerous, etc.).

Subject Behaviour: The key is to understand that an officer's intervention is based on the totality of the situation and that the subject's behaviour alone is not sufficient to dictate the proper intervention option.

Striking/deploying and moving (when deploying an intervention option or striking, it is suggested to move away from the original position so that a focused subject can't simply attack the last known position of the officer;

Creating Time and Distance (the longer the officer can acquire and analyse information, the better chance he/she has to use the proper intervention option)

Moving to cover (given that cover is available, this will have the same effect as creating time and distance. Once to safety, an officer should be able to process the information given more effectively)

Complete Disengagement (To a position of containment while awaiting back up for example). The officer must understand and accept that, at times, a complete disengagement is impossible (for example, in the case of an active shooter) because it is responsibility of the police to protect and preserve life.

Officer's Perception: The totality of the situation is processed by an individual who brings his/her own set of skills, knowledge, gender, experience, fears/confidence, fatigue/fitness, etc. The officer will continuously assess the risk and formulate an intervention option based on the totality of the situation as processed through his/her perceptions. These perceptions must be reasonable. Two officers facing a seemingly identical situation will likely intervene differently. The intervention should be measured against the actions of a reasonable, trained and prudent officer faced with the same set of circumstances.

*****. The initial multiple member response on June 4 was robust and appropriate, based on the original complaint, the IMIM and RCMP backup policy. A sufficient number of members were dispatched, directed and responded. At the time of the first report, the end of a dayshift and the beginning of a nightshift were overlapping. Several members who had finished their shift were still in the office and returned to duty as the incident escalated. *****. The OCC obtained adequate detail during the two initial complaints from Pioneer. This information was broadcast and responding members identified. This was the beginning of the risk assessment process.

Codiac detachment has policy on containment and perimeters wherein *****. Members were effectively directed to appropriate locations by the OCC in order to set up an initial perimeter and they were doing so with emergency equipment engaged. Without knowing the SOC's intent, setting up a perimeter to acquire visual contact was the correct police response. The members who knew the neighbourhood were assisting in making the perimeter as effective as possible.

The recommendations relating to the function of the OCC are found in section 7: Operational Communications.

Cst. Doiron was the first member to arrive at Pioneer Avenue, and he was able to gather additional information which he then relayed to the rest of the responders. This included that the SOC appeared irritated. This detail should have heightened the responders' risk assessment. The road supervisor for the incident, told Doiron to stay out of the woods and wait for PDS. Cpl. Cloutier immediately recognized the need for PDS to track the SOC and contacted the on-call PDS member. Cst. Johnstone was the first member to arrive on Mailhot and he asked about getting civilians into their houses and Cpl. Maclean responded that this would be a good idea. Residents who were told to return to their homes report that members were clearly taking the threat as significant. All of these actions were tactically sound. Throughout the incident some residents ignored the orders of police to clear the area and became a distraction.

There are two specific actions which cause concern, that were not taken by responding members, despite the risk assessment and situational factors known at the time. Even though it had been clearly communicated that the SOC was carrying firearms, none of the responding members put on their HBA, and only one member who departed Codiac detachment to attend took the initiative to bring a shotgun. *****. A comprehensive discussion of the weapon and HBA choices will be held below.

The recommendations relating to Hard Body Armour and firearms are found in section 5: Equipment and Weapons.

As the perimeter was set, responding members were utilizing appropriate radio communication. Their vehicles and locations were confirmed through the OCC. Cst. Dubois was asked to speak with more witnesses to potentially identify the SOC.

The situation began to change rapidly when Cst. Daigle saw the SOC. At first visual, Cst. Daigle asked for all members to "clear the air" (stop using the radio), so he could provide everyone with updated information. Cst. Daigle reported he had seen the SOC and where he was walking. At this point, because he could see the suspect, he took on the lead role in response to this incident. The other responders began to reposition based on his information. Verbal intervention was an option for Daigle at this point, but Daigle's perception was the SOC was beyond pistol range. Giving away his location may have put him at a significant tactical disadvantage should a gunfight ensue, given that the SOC was in possession of a rifle. Daigle's decision to try and maintain visual contact with the SOC was also appropriate, given that the dog handler had not yet arrived and the SOC was entering a residential area.

Shortly thereafter, Cst. Daigle lost direct visual contact with the SOC, but believed he knew the general area where he was headed as being behind the residences on the south side of Bromfield. Other members quickly converged on foot from various perimeter positions to Cst.Daigle's location, in order to provide him with assistance and attempt to reacquire visual contact with the SOC. By closing in on the area where the SOC was believed to have last been seen on foot, members left their vehicles. Unfortunately, they also left behind their HBA *****. Any location information for individual members would now have to be transmitted via radio. This fact hampered both OCC and watch supervisors in determining where members were at any given time.

At this point the members had to reacquire visual contact with the SOC in order to initiate any form of verbal intervention and coordinate effective containment. Situational factors affecting the collective risk assessment of the responding members included:

Layout of this particular neighbourhood;

Presence of numerous civilian bystanders;

Members' lack of appropriate long guns;

Unknown time delay before PDS arrival;

Behaviour and unknown intentions of the SOC.

Each of these considerations contributed to their decision to close in quickly. Members' perceptions of the danger to the public impacted their risk assessments and created an understandable sense of urgency in trying to locate the SOC. Obtaining sight of him again would eliminate the need to wait for PDS to commence a tracking operation, enable containment plans to be implemented, and provide crucial intelligence as to his actions and behaviours.

Cst. Daigle met up briefly with Cst. Gevaudan at some point after visual contact with the suspect had been lost. Subsequently, as a team, they used the concealment of the wooded area behind the residences on 15 and 19 Bromfield as best they could to hide their approach towards where they believed the SOC was located. Cst. Gevaudan advised other members over the radio where he and Cst. Daigle were positioned. Radio communication between Cpl. Cloutier and Cst. Doiron clearly indicated that the PDS member (Cst. Ross) was a few minutes from being mobile. At the same time Csts. Mitchell, Johnstone and Doiron were yelling for people to go into their houses on Willshire, which was a prudent measure.

The specific communications between Cst. Daigle and Cst. Gevaudan as it related to the tactical plan they devised is unknown. Their discussion was not broadcast over the radio, and as such no other members were aware of the details of their strategy for continuing to search for the suspect, or what to do once he was located.

It has already been noted in this report that the reliability of the individual and collective recollections of members has been inconsistent. This is understandable given the traumatic incidents that followed, and is perfectly normal. Based on this reality, the Review Team is required to make an assessment of what took place during those critical seconds where shots were first fired by incorporating information which is known to be reliable with potentially less-reliable eyewitness accounts. From a radio transmission, it is established that Csts. Gevaudan and Daigle were together in the wooded area beside 15 Bromfield. Cst Daigle is seen on surveillance video from the front northwest corner of this same residence and Cst. Gevaudan is not with him. Cst. Daigle is seen on the video to make a radio transmission via his portable, which has been matched to a recording where he asks Cst. Gevaudan to provide his (Gevaudan's) location.

No shots had been fired up to this point. Several other members subsequently appear on the video footage. Several head out towards Bromfield while others (including Cst. Daigle) move along the front of the house towards the garages on the northeast side of the house. Cst. Gevaudan is not among either group.

Cst. Gevaudan apparently decided to move behind the residence at 15 Bromfield. We cannot know the specific reason(s) for this decision; if he saw Bourque he did not communicate this fact on the radio. If he decided to reposition himself based on an individual assessment of the situation, this was not communicated to Cst. Daigle. He did radio for members to clear the air. Subsequently, while members were moving across the front of the house, shots rang out from behind it. Cst. Gevaudan is almost immediately heard on the radio yelling "He's shooting at me!"

He is alone at this point, armed with only his pistol, and the suspect is armed with a high-powered, semi-automatic rifle. The suspect is in a static firing position, which affords both cover from pistol fire (in the form of trees and possibly a depression in the ground) as well as concealment (trees, foliage, and his camouflage clothing). Cst. Gevaudan, in contrast, is more visible in his uniform, which is in stark contrast to his surroundings. The fact that witnesses in neighbouring houses were able to see member uniforms through the foliage supports this. The tactical advantages are overwhelmingly in favour of Bourque.

What Cst. Gevaudan saw, and why he decided to remain behind the house when Cst. Daigle circled around to the front of it, is not known. What is known is that his life was in immediate danger, and his overwhelming consideration would have been to seek cover. His actions were consistent with this thought process. He showed remarkable awareness by calling on the radio that he was under fire. Without the benefit of a full understanding of these critical few seconds, these are the only definitive conclusions we can prudently draw.

Several shots are fired in close succession. Members are seen reacting to the gunfire on the surveillance footage. Bullet entry and exit holes in several trees, recovered empty rifle casings, and rifle fire damage to property located behind 15 Bromfield and to the back of the house itself, provide information as to where Bourque was positioned at the time he opened fire. They also provide information as to the movements of Cst. Gevaudan in response to being fired upon. We do not know exactly where he was positioned when he first drew fire, but he ran towards an open area behind the adjacent residence (19 Bromfield). Why he chose to run in this direction is something we will never know with any certainty. He was reacting to being fired upon unexpectedly, and was forced to make a split-second decision to try and save his life. What we do know is where he ultimately fell to the ground as a result of incurring two gunshot wounds, and as such can track his movements based on the firing pattern of the suspect.

As per the IMIM, if the SOC was aware of the police presence and believed they were there because of him, they would have ascertained that at a minimum he was displaying active resistant behaviour. This behavior, combined with the fact that he was known to be armed, wearing camouflage, and hiding among the trees, raised the risk assessment of the responding members significantly.

Tactically, Csts. Gevaudan and Daigle had very little time to discuss options in view of the circumstances. They were also at a tactical disadvantage in terms of firepower (considering the description of the SOC's guns).

Subsection 25(1) of the Criminal Code authorizes a police officer who is acting in the administration or enforcement of the law to use as much force as necessary. Given the situational factors, all members approaching the SOC should have been ready to respond immediately with lethal force should it become necessary.

Once they sighted the SOC again, the appropriate intervention option given the totality of the situation was verbal intervention with *****.

*****.

The Review Team spoke with many members who indicated that a call of a suspicious person with a firearm was not unusual for Codiac. While the initial response and approach to the subject displayed appropriate risk assessment and decision making (pistols drawn and pointed toward subject), the perception that this may be another routine call may have been a factor in that no member was in a position to return fire.

1.1 It is recommended that additional training on lethal force over-watch be provided to members.

Cst. Gevaudan was forced to tactically reposition because he was under fire with limited concealment. Without intimate knowledge of these surroundings, he could not have known that his chosen path would result in him being more exposed to additional rounds from the SOC. Cst. Daigle was the first to reach the corner of the garage at 15 Bromfield, followed by Cst. Nickerson, seconds later. Csts. White, Mitchell, Martel and Cpl. Maclean were moving around 15 Bromfield as shots were being fired. Cst. Nickerson saw a portion of Gevaudan's run but did not see the shooter. Csts. Johnstone and Doiron were near the corner of Mailhot and Bromfield.

Cst. Gevaudan broadcast he was being shot at and was now unaccounted for and not responding to radio calls. Members quickly ascertained the shooter was using a high powered firearm capable of firing multiple rounds in rapid sequence (they had just heard multiple gun shots). Tactically, armed with service pistols and one shotgun, they were at a disadvantage due to the superior fire power and range of the shooter's weapon. At this point, it would have been appropriate for the members to seek cover, conduct a risk assessment and establish a rescue plan for Cst. Gevaudan and a plan to neutralize the threat.

The time between the shooting of Cst. Gevaudan and Cst. Ross is just under two minutes. After the initial shots the shooter heads towards Mailhot. The members who went to the front of 15 Bromfield were now fully occupied with seeking cover and locating Gevaudan. Ross, who had just arrived in his PDS vehicle, was quickly able to engage the shooter. Upon reaching Bromfield, Ross was immediately directed down Mailhot by a member near the corner of Bromfield and Mailhot. Cst. Ross saw the shooter and attempted to stop him. There were still people on Mailhot near the SOC and this may have affected how Cst. Ross chose to approach the shooter.

The Ops NCO began to dispatch more members based on shots being fired at Cst. Gevaudan. A broadcast in plain language stating that the suspect had just shot a member with a high powered rifle was not made, even after the road supervisor reached Gevaudan. This critical information could have changed the response and risk assessment of other members arriving at the scene as back up. None of this second wave of members utilized HBA even though a member had been shot. It is clear from the Ops NCOs question on the radio, "who's injured?" that he was unaware a member had been killed (members were still performing first aid on Gevaudan). This led to confusion around how many ambulances were required and where.

The road supervisor, having lost his radio, did not hear Cst. Ross' broadcast. This combined with applying first aid to Cst. Gevaudan, left him unable to assess the overall tactical situation. The Ops NCO had less information, knowing only what was broadcast on the radio. Without situational awareness the ability of any supervisor to effectively intervene at this point was minimal.

There was a tendency for members to avoid using plain language on the radio due to a lack of encryption and a desire to avoid broadcasting details to the public. Moncton has avid monitors of police transmissions and unfolding calls were routinely posted to a news chasing group on social media. RCMP training instructs members to use 10 codes (despite their being widely available in the public domain) for this purpose. Members should be encouraged to use plain language in crisis situations.

The recommendation relating to the use of plain language is found in section 7: Operational Communications.

After the shooting of Cst. Ross, the term "active shooter" started to be used by members and the telecoms operators who were calling in additional resources and informing senior managers of an "active shooter". Active shooter is associated to RCMP IARD training ***** IARD training. ***** and moving from cover to cover. Even after seeing or learning that Cst. Gevaudan had been shot, members continued to track the shooter in an effort to stop him, despite the danger he clearly posed to police.

One member who did not feel IARD was the appropriate tactical response was Cst. White, a Basic Firearms Instructor (BFI) and IARD instructor. Immediately after leaving Bromfield Court he moved on his own down Mailhot, from cover to cover opting for speed. After closing the 260m distance to Cst. Ross' vehicle in a couple of minutes, he saw the shooter further down the street. Cst. White's decision not to attempt lethal force with his pistol when he observed Bourque on Mailhot was tactically sound. Given the distance involved (about 90m) and only being armed with his pistol, Cst. White would have been at a severe disadvantage in an engagement with the SOC. He effectively took cover behind the PDS vehicle and radioed his situation, thus giving other responding members the current location of the shooter. Once the road supervisor arrived, he requested ERT in recognition of the shooter's firepower and the tactical limitations of general duty first responders.

The recommendation relating to the ***** Member Training and Officer Safety Skills.

Cst. Martine Benoit drove to the area with lights and sirens activated via Mountain Road. She turned onto Hildegard Drive just as the OCC reported the suspect was at Hildegard and Mailhot. The tactics and risk assessment of both she and Cst. Nick Gilfillan were based on this information. Cpl. Cloutier directed them to attend the scene of the shooting; however, there was no discussion of specific roles for them. A witness pointed out where the SOC had entered bushes down the road. She parked her vehicle at the intersection and assessed the situation. She had just decided it was best to stay in her car when she began to take fire. At this point she employed the best reactionary tactics possible *****. Benoit calmly radioed that she was being fired upon at and the shots were coming from in front of her vehicle, giving other responders a good indication of the shooter's location. Once her vehicle was disabled she clearly transmitted this fact and asked if it was safe to get out of her car. She then requested assistance. She was concise in her request and conveyed pertinent information to inform her own risk assessment and that of her colleagues.

Cst. Eric Dubois answered Cst. Benoit's call for assistance. He drove to her location and stopped his vehicle next to hers where he felt it would provide additional cover from the shooter. He then made a sound tactical decision by getting himself and Cst. Benoit to the back of the police car thereby placing the entire vehicle between them and the shooter. While attempting to spot the shooter's location by raising his head periodically from behind cover, Dubois was injured by bullet fragments or secondary projectiles. He subsequently attributed his being hit to having popped up from the same location too consistently. Dubois ran to the fire station after seeing the gunman cross Hildegard and assuming he had left the scene. Cst. Benoit made the decision to stay behind cover and called for someone to get her. Both members' assessments were reasonable at the time. Cst. Benoit had not seen the suspect leave and was not convinced he had finished shooting at them. Cst. Gilfillan recognized that Cst. Benoit needed assistance in order to move to cover at the fire station. He drove his police vehicle alongside the vehicle where Cst. Benoit was taking cover. Once she was inside his vehicle, he was able to safely return to the fire station.

While the shooting occurred at Hildegard and Mailhot the initial responders continued to follow the broadcast sightings of the shooter. Csts. Mitchell, Doiron and Martel traveled as a team down Mailhot to Kenview Drive, then up toward the back of the fire station, which was the reported location of the shooter shortly after they began their pursuit. Cst. Mitchell commandeered a civilian vehicle with the intent of camouflaging herself, moving more quickly, and potentially running down the gunman. Her decision to commandeer the vehicle was a sound tactical decision and it shows that she had realized that police were the gunman's sole targets. Cst. Mitchell at no time came in contact with the gunman and she transported Cst. Dubois to the hospital.

Cst. Goguen, from Southeast District, unknowingly drove directly to the shooter's location as Bourque was in the process of firing multiple rounds at police vehicles parked at the intersection of Hildegard and Mailhot. Southeast District uses a different radio frequency and is dispatched through the OCC at "J" Division HQ in Fredericton. Members are able to use a scan feature which allows them to hear radio broadcasts from other channels which are overridden by any simultaneous broadcasts on their own channel. Cst. Goguen believed her scan button was not functioning properly and had insufficient information to make an informed risk assessment. She heard gunshots, started to turn her car around and was hit by the gunfire. After being shot she drove to safety a few blocks away on Penrose Street, where members transported her to hospital. Cst. Goguen's quick reaction to reposition her vehicle was a factor in saving her life.

The shooting of Cst. Goguen added to the chaos of the situation. As she was dispatched on a different channel, no one on Codiac's radio channel was aware Cst. Goguen had been shot. Codiac's OCC only learned she had been under fire when someone found her bullet riddled car. They mistakenly believed and shared that she had been shot on Penrose Street where her car was parked, adding to the confusion regarding the gunman's movements.

During the period of 19:51 to 20:05, overall tactical awareness was poor. The OCC was overwhelmed by calls about SOC sightings, positioning of incoming back-up and dispatching medical care for wounded members. Members on the scene continued to move toward the sound of gunfire and no individual member took charge over the radio leaving OCC dispatchers to do their best to continue to coordinate operations from their vantage point.

Accurate risk assessments were difficult as members were calling for ambulances to multiple locations. Sightings were being reported based on caller location (as opposed to suspect location), then broadcast out of order. There were wounded members in need of medical attention. There were two erroneous reports broadcast about shots fired on Lonsdale and the SOC being seen at the (non-existent) corner of Lonsdale and Mailhot as well as a report of him being on Foxwood moving towards Ryan when he had, in fact, already crossed Hildegard and was moving towards Mailhot. Based on the radio traffic, it would have been nearly impossible to form an accurate tactical view of the situation. The current locations being broadcast by members were interspersed with stale or inaccurate information from 911 callers being relayed by the OCC.

It is around this time that the Hildegard Fire Station became a staging area. Members dispatched from Codiac and Southeast District after the first shooting were told to go there. Cpl. Whittington, Cst. Gilfillan, Cst. Verret and others arrived there after the shooter had left and traveled beyond the intersection of Mailhot and Hildegard. By this point, members had established that the shooter was only targeting police officers. Those gathered at the fire station made sound *****, donning their HBA and positioning themselves to engage the shooter whose whereabouts were unknown. Given they were already inside the "shooting area", this was the most appropriate action.

Some members went to fire station as it was the last known location of the suspect. As they gathered there other members joined and others were dispatched to the fire hall believing this was a location to stage. Since the shooters' whereabouts were unknown it was not a safe location and some members were not aware of their role once they arrived at the fire hall, or who would be directing them once they got there.

Upon hearing shots being fired further down Mailhot and hearing the erroneous broadcast that a civilian was down in the same area, members' risk assessments and subsequent response should have changed drastically. This was the case for several members who began tracking toward that location, including Cst. Gilfillan who suggests others don HBA. He was the first member to recognize this critical officer safety component.

Video of the fire station from the period after Cst. Benoit was retrieved from her vehicle until Cst. Larche was shot shows a lack of coordination and supervision. At least six members were present. Many vehicles and pedestrians can be observed passing by. No direction was given by any member to block either end of Hildegard. It is not until Forensic Identification Section (FIS) Cpl. Denis Leblanc heard about the situation that he responded and offered to block westbound traffic on Hildegard Drive. Unfortunately, no one decided to block the other end of Hildegard at Ryan Street.

The recommendations relating to supervision are found in section 3: Supervision During the Entire Incident.

The response of the four Major Crimes Unit (MCU) members began immediately after the first shots. They returned to the office to get shotguns and made their way toward Hildegard in four cars. The Codiac detachment members and supervisors were not previously aware MCU was working and the Ops NCO did not hear the radio broadcasts indicating they were responding to assist. The OCC broadcast confirmation they were on the way, but no one at the scene or supervising gave them a duty. During the drive toward Hildegard, Cst. Larche broke off from the two cars ahead of him and went to Mailhot and Isington. There was no discussion on the radio about this action, and the other members of the Major Crime Unit do not know why Larche made this decision.

Cst. Larche told the OCC where he was and that he would be out of the vehicle. He got out with a shotgun and immediately began scanning the area for the SOC. The gunman was concealed by the trees in close proximity to where Larche was standing by his vehicle. The gunman identified Larche as a police officer because he was wearing SBA and began shooting at him. All shots were fired from less than 20m. It must be noted that Doug Larche was very seriously wounded before he could fire his shotgun. After being knocked down by the first bullet(s) he did not give up; he struggled back to his feet and drew his pistol to engage the gunman. Cst. Larche fought until the end, firing seven rounds, the last after being hit by what proved to be the fatal shot.

Cst. Larche was shot at 20:05. At that time, the only members south of Hildegard were Cst. Larche and possibly Cst. White who was tracking on his own. All the other members deployed to the scene were occupied in various capacities. Tactically the situation was not under control.

The shooter proceeded into the woods on the south side of Ryan Street as the members tracked down Mailhot, eventually reaching Cst. Larche. Cst. White reached Cst. Larche after civilians had already covered him. White then moved Cst. Larche into a nearby residence and remained with him.

Once at the end of Mailhot, members began to radio their positions in to the OCC and take the best cover they could facing the woods. Members did not advance further into the woods in pursuit of the SOC. This was a tactically sound decision.

Section 3: Supervision During the Entire Incident

Question from the Commissioner: Does the manner in which this incident was supervised suggest any areas for improvement?

On June 4, 2014, supervisors in Codiac were confronted with a situation that in many ways exceeded what supervisors are trained to deal with. They were faced with a crisis situation that evolved quickly, was operationally challenging and highly emotional.

The level of supervision required to manage an incident is directly proportional to its scope. As a paramilitary organization the RCMP works within a rank structure where increases in rank come with corresponding levels of responsibility.

Supervisory Structure of Codiac Detachment

Codiac detachment has an Officer in Charge (OIC) at the Superintendent level, and an Inspector who is the Operations Officer. The Codiac system of general duty supervision involves uniform officers assigned to two watches who work 11.20 hour shifts.

The two watches have Staff Sergeants in charge who work during day time hours that jointly cover the full seven days. The S/Sgts. manage two Sgt. Operations (Ops) NCOs who cover the core working hours, 06:00 to 04:00. The Ops NCO manages Corporals whose job is to supervise two groups of Constables. One group, the responders, answers calls for service and cover the shifts 24/7. This group does not carry investigations past their assigned shift. Matters requiring follow-up investigation are assigned to the other group of Constables, the Further Investigation Team (FIT) who manage lower level investigations involving persons and property related offences. These Constables do not work 24/7, however, are in uniform and expected to complement the responder group for serious matters.

Supervisory Structure in Codiac During the Incident

On the evening of June 4, supervision in Codiac consisted of the following:

Operations NCO, Cpl. Jacques Cloutier was the acting Sergeant. He was scheduled to work until 04:00 hrs. The Ops NCO is the manager of operations and is accountable for providing overall operational direction. The Ops NCO is responsible to keep a strategic view of events during the course of the shift whereas Team Leader Corporals are more tactically focused. The Ops NCO is tasked with making decisions on the activation of support sections and seeking additional resources as required (GIS, MCU, Air Services, Ground Search and Rescue, etc.).

The Ops NCO monitors all calls for service through CIIDS and has the final authority on the management of member deployment. The Ops NCO supports the Team Leaders by providing direction and uses their expertise at the scenes of major incidents to ensure overall direction is being followed at the tactical level.

In Codiac, the Ops NCO primarily works from the office and does not normally attend calls for service.

Team Leaders, Cpl. Peter MacLean and Cpl. Lisa Whittington were the first line of supervision. Cpl. MacLean was the evening supervisor, working until 21:00 and Cpl. Whittington was the night supervisor working until 06:00. Both Team Leaders were on shift and in the office at the time of the initial call.

The Codiac Operational Communications Centre does not have a formal supervisory function, but they play a critical role in the management of police response. During the incident, OCC dispatchers provided direction based on incoming information. The Codiac OCC consists of two dedicated 911 call takers, one dedicated fire dispatcher and an assistant dispatcher. There is also one dedicated RCMP dispatcher along with an assistant dispatcher for a total of six staff working any given shift. The main RCMP dispatcher communicates with RCMP members via the single live monitored radio channel. The assistant dispatcher picks up the overflow from the main dispatcher.

Resources available in addition to the uniform presence included a four person Major Crimes team who were working on an unrelated matter in plain clothes and unmarked vehicles. This team, which included Cst. Doug Larche, was led by a Cpl. who did not take on a substantive supervisory role. This is standard practice as support resources fall under the established command structure for general duty calls.

The neighbouring Southeast District had four members working with an acting Cpl. in charge. He did not take on a substantive supervisory role either as he too fell under the established command structure.

Initial Call

The initial call was well managed and coordinated by the OCC, Cpl. Cloutier, Cpl. MacLean and Cst. Doiron and lasted approximately 20 minutes, until the suspect was located near Bromfield. Cpl. Cloutier ensured all available resources were dispatched and that Cpl. MacLean was assigned to attend in person as the road supervisor. Cst. Doiron was the first officer to arrive on scene and made a sound tactical decision in requesting additional resources, assisting with the establishment of a perimeter and providing situational awareness. Cpl. MacLean provided direct supervisory oversight, he ensured the perimeter was held, requested PDS, obtained a more accurate assessment of the suspect, advised members against venturing deep into the woods until PDS arrived and instructed civilians to leave the area. Cpl. MacLean's supervisory actions were a very good example of how this type of call is initially managed. It must be noted however, that not a single member responded wearing available HBA and only one deployed with a long gun.

Codiac detachment has a policy on containment and perimeters wherein *****. The OCC did a commendable job having members contain the suspect and isolate him in the wooded area.

Cpl. Cloutier was at the office monitoring the radio, telephone, and the CIIDS terminal. He was also coordinating PDS and ensuring members had left the office to assist in the response. Cpl. Cloutier relied on information from the scene and did a very good job of assembling resources. He was also responsible for monitoring all other calls for service in the detachment area.

Cpl. Cloutier's ability to effectively manage this incident was impacted by a lack of adequate mapping *****. A recommendation in relation to this can be found in the section on the OCC.

Locating and Following the Suspect

The amount of frontline supervision during this phase was minimal as the road supervisor was still enroute to the scene.

As the perimeter was being established and members were positioning, the suspect was located by Cst. Daigle. He radioed the position of the suspect and, knowing backup was on the way, decided to follow him on foot in an effort to keep him in sight. At this point the road supervisor was aware that PDS would be delayed, thus he did not direct Daigle to hold his position as he had done earlier. The road supervisor was making his way to the scene to provide direct supervision and was allowing Cst. Daigle to direct the approach of members. This was appropriate given Cst. Daigle could see the SOC.

Engaging the Accused

The members' approach to the SOC evolved rapidly and unexpectedly. It was a challenge for the road supervisor to provide direct supervision given he was just transitioning from his vehicle to go to the scene on foot. He had broadcast that he was enroute over the radio to ensure members were aware of his location. Unfortunately his portable radio had accidentally detached from his belt as he exited his vehicle and he was not in possession of a cell phone. During this critical time he had no communication with the other members.

3.1 It is recommended that members be in possession of a cellular phone and police radio while on duty, as a required part of Service order #1.

Shots Fired

The road supervisor was moving into position to meet with Cst. Daigle and Cst. Gevaudan when shots were fired. This was a rapidly evolving and dynamic situation where the SOC was moving toward a busy neighbourhood leaving little opportunity for discussion between members and supervisors as to how they would tactically handle the situation.

*****. This would have been valuable information for providing tactical advice.

Once the shooting of Cst. Gevaudan occurred, radio communication intensified. Poor situational awareness during the moments that followed can be attributed, in part, to poor radio protocol. Members were not using plain language, which caused confusion as to the severity of the situation. This made it made it difficult for supervisors to give direction. Supervisors indicated a reluctance to talk over the radio because they did not want to tie up vital airtime, potentially preventing a member in direct danger from being able to communicate. The Ops NCO was over-tasked monitoring radio traffic, making calls and other logistics with nobody to delegate to. Had he been in a position to delegate some of these duties it may have offered him the opportunity to better manage the incident.

The level of supervision during this phase should have transitioned to one of command and control. Urgency of action took precedence.

As Cst. Dave Ross approached the scene his situational awareness may have been limited to his brief telephone conversation with the Ops NCO and the OCC before any shots were fired. He likely heard the broadcast location of the SOC and "shots fired" and "he is shooting at me". Cst. Ross radioed "I have a visual and will be on takedown in a second." Disrupted radio chatter immediately followed this transmission and another member stated more shots were fired. Cst. Ross was killed as he drove toward the suspect in his police vehicle.

The road supervisor would not have heard Cst. Ross' broadcast because he did not have a radio and was the first member to find Cst. Gevaudan after he was shot and killed. He immediately began providing first aid to Gevaudan therefore he was not in a position to assess the overall tactical situation at that point.

The Ops NCO had less information, knowing only what was broadcast on the radio. Without situational awareness, the ability of any supervisor to effectively intervene at this point was minimal. However, as time passed no supervisor obtained a clear understanding of what was occurring therefore could not provide direction. ***** it could be understood given the emotional gravity of the situation and lack of training and experience in dealing with this type of tragedy.

A radio broadcast that explained Cst. Gevaudan had been shot by the suspect in plain language, thus providing critical situational awareness to the other members, did not occur. This could be explained by virtue of the fact that members including the road supervisor were putting their lives at risk in a highly emotional effort to provide first aid to Cst. Gevaudan in what was a tactically dangerous location.

3.2 It is recommended the RCMP examine how it trains frontline supervisors to exercise command and control during critical incidents.

For a recommendation related to plain language, refer to section 7.

There were eight members assembled near the scene of the shooting either performing first aid on Cst. Gevaudan or providing cover. Cst. White and the road supervisor decided to leave the group and pursue the accused. Although the actions of both members were very brave, at this point the road supervisor transitioned from his role of supervisor to first responder without discussing a tactical plan with the six Constables before he left.

Nobody established a command presence during this period. Members were acting on their own accord without a unified tactical plan. Order could have been established if a supervisor had obtained a situational update and requested members report their positions. Most members at this time were on foot. Nobody at a supervisory level had an overall view of where resources were positioned and this remained the case for the next hour or more. Members were taking heroic and commendable action as individuals and in small teams, however, they were not coordinated with a common plan and direction.

As the situation evolved and additional resources became available to the Ops NCO, a scribe should have been assigned to record decisions, resource allocations, member positions and other important information. This would have facilitated a smoother transfer of command to the CIC and an accurate record of events.

At this point two members were shot and killed but many members involved were unaware their colleagues were dead. This impacted their risk assessments.

Once the Fire Department arrived and they took over CPR on Cst. Gevaudan, the remaining six Constables assembled in two teams of three and advanced in search of the accused using IARD contact formations. No supervision was sought or provided to these teams and they were not coordinated as a whole. The Ops NCO was still unaware that two members were dead. An uncoordinated situation persisted. At 19:51 the road supervisor asked over the radio for "ERT, we are going to need everything we got".

Hildegard Drive Shootings

Although the shootings of Csts. Gevaudan and Ross occurred only two minutes apart, the time between the shooting of Csts. Ross and Larche was 18 minutes. During this period, Csts. Dubois and Goguen were wounded and Cst. Benoit was fired upon on Hildegard Dr. There was an opportunity for supervisory direction to the members present during this time.

The road supervisor says in his interview with the Review Team that he was leaving it to the OCC to direct members because they had the mapping system and the vehicle location data. *****.

Although the OCC was doing an exceptional job in coordinating the members on scene, a senior NCO with tactical experience posted to the OCC during this critical incident would have been in the best position to coordinate resources with real time, accurate information.

Recommendation 7.9 in the Operational Communications section addresses the need to post a Senior NCO to the OCC.

The road supervisor was the supervisor with the best situational awareness and may have been able to provide tactical direction from the scene. The Ops NCO, who was alone in the office for the hectic half hour after shots were fired, was flooded with radio, telephone and other concurrent activity that was necessary to bring in additional resources. He did not have adequate situational awareness to provide proper tactical direction.

The night supervisor was assigned by the Ops NCO to attend at approximately 19:47. She was dealing with a prisoner at the time and had to secure him before responding. She was heard on the radio responding at 19:55 with her siren activated, asking to be sent a copy of the dispatched file. She drove up Mountain Road and onto Hildegard; because she was aware Hildegard was where the members were. Once there, she parked at the fire station. Several significant developments occurred on Hildegard Drive, where the opportunity to take some supervisory action would have been possible. However, the road supervisor was not fully aware of the planning and action taking place as members were taking it upon themselves to act. The road supervisor did not play an active role in the supervision of the incident. Video of the fire station area from the period after Cst. Benoit was retrieved from her vehicle until Cst. Larche was shot shows a lack of coordination and supervision, while at least six members were present. Many vehicles and pedestrians are observed passing by. No direction is given to block either end of Hildegard. It was not until FIS Cpl. Denis Leblanc hears about the situation that he responds and offers to block westbound traffic on Hildegard Drive. Unfortunately, no one decided to block the other end of Hildegard at Ryan Street.

Supervisors at this point should reasonably be expected to direct perimeter control and teams. Members were not provided guidance and took it upon themselves to act. Many members participated in courageous and selfless acts and placed themselves in danger.

Advance to Isington and the Shooting of Cst. Larche

The response of the four Major Crime members began immediately after the first shots. The Codiac detachment members and supervisors were not aware MCU was working and the Ops NCO did not hear the radio broadcast that they were responding to assist. The OCC did note they were on the way, but no uniformed supervisor was aware. Cst. Larche broke off from the two cars ahead of him on Hildegard and drove to Mailhot and Isington where he left his vehicle and was killed after encountering the suspect.

The accused was observed after the shooting fleeing into the woods behind Isington Avenue toward Ryan Street This would have been the point last seen for the next several hours.

Post Shooting Manhunt and Later Sightings

This phase of the incident should have brought stabilisation and enhanced coordination to this crisis, as the intensity of the observable threat diminished. Although no additional shots were fired, resources remained in a state of disarray, with members responding in an uncoordinated manner to reported sightings of the accused and not holding their perimeter positions.

Many members were not briefed and took it upon themselves to locate and respond to evolving situations without any person in charge being aware. The OCC and others were assigning members to general and non-specific perimeter locations, however, no direction was provided over the radio for members to report positions, nor was anybody keeping track of these locations, their identities, additional firepower on site, or the duration of the shifts. Some members worked in excess of 24 hours without a replacement. The fatalities were not known to some of the members or supervisors who responded to the initial call until approximately 21:00, others did not know the full extent until many hours after this. A roll call or situation update was not conducted to establish if all resources were accounted for.

Members on duty did not receive a detailed update from a supervisor about the threat they were facing. The awareness members had was circulated by word of mouth. At the point last seen, adjacent to Ryan Street and Wheeler Boulevard, there were members with marked police vehicles who were exposed without knowing the shooter was last seen nearby.

Members from other Districts, Detachments, Municipal agencies and "H" Division were starting to arrive and there was no mechanism to track and coordinate these resources. Challenges with tracking police vehicles from outside Codiac Detachment will be dealt with in Section 7 of the Review.

Command evolved from the initial Ops NCO, with the arrival of the Codiac Operations Officer at 20:20 and both managed different aspects of the situation from the same office. The Ops Officer became the Incident Commander at that point, a scribe was appointed and people were given specific tasks. The execution of those tasks was not monitored and various people were continuing to conduct unassigned tasks without direction. The command structure was not clear to those on the ground. Both the Ops NCO and Ops Officer were extremely busy and the situation in Codiac detachment was intense and emotionally draining. Both men must be recognized for their dedication and the effort they put forth under extreme circumstances.

Supt. Tom Critchlow, a trained Critical Incident Commander and former Operations Officer at Codiac detachment, was not working but heard about the situation and went to Codiac to lend assistance and he stayed to provide advice to the Ops NCO and Ops Officer, *****.

Even though Command transferred from the Ops NCO to the Ops Officer, an official briefing and transfer of Command did not take place and the Ops NCO believed he was in charge until he went home at 06:00 on June 5. The Ops NCO's actions and decisions were not recorded.

Insp. Leahy was the assigned Critical Incident Commander (CIC) who had to travel to Moncton from the Fredericton area. The actual time command was transferred to the CIC is somewhere between 00:30 and 03:00 on June 5. A more precise time could not be established. The CIC indicated he permitted the Ops NCO and Ops Officer and Supt. Critchlow to continue commanding the incident from Codiac detachment while he worked on getting his Command Post (CP) up and running at the Moncton Garrison. He did not feel that he was in a position to take over until such time as his CP was established. He feels that his CP was not ready to assume overall command until about 03:00, at which point things began to normalize. As outlined above with regards to the lack of recorded information, it was difficult for the CIC to obtain information he required on what had occurred.

An example of the confusion that was taking place related to a credible sighting that came in at 00:39 near the point where Bourque was last seen. An ERT response ensued but was not well communicated, as some of those in command were unaware of the ERT response and did not have a record of it.

Although it is indicated there was an absence of clear direction from commanders who were performing various functions, some members took it upon themselves to take a leadership role. Members interviewed by the Review Team commented on two specific examples involving a coordinated effort to establishment a perimeter as well as a staging area for ambulances.

The morning of June 5, members were provided with relief. In many cases, members were sent home without a debriefing. Proper debriefings would have provided valuable information to the Commanders who took over.

Dealing with the Influx of Responders

At least two supervisors made the call for additional resources from other police agencies and districts. A large number of members were eventually on site in Moncton and the command structure was not in place to deal with the influx of resources. This could have proven very dangerous; given the accused was in close proximity to the perimeter members who were positioned near the most recent sightings. Several members described not receiving or seeking direction and just "drove around", many of whom were not tracked by the Moncton OCC.

Requesting additional resources with no plan to stage, manage and deploy them created an additional burden for already overburdened supervisors.

Summary of Supervisory Challenges

In responding to and containing the initial threat, supervision was very effective. However, the moment shots were fired; something that is not routine, chaos ensued. Chaos is unavoidable in the first moments of a dynamic and deadly situation; however, order should be restored as quickly as possible through supervisory coordination in the form of Command and Control. Structure, even when the structure offered is not perfect, is expected by members in a crisis.

At times, supervisors lost sight of their command role. Assignments were provided for various functions, however, regular reporting back and situational assessments were either not done or were not filtered through one central point of command. While everyone involved has a responsibility to contribute to overall situational awareness, it is the duty of a supervisor to ensure this is done effectively. This incident demonstrates the need to establish command and control during the early stages of a critical incident.

Supervising an incident as dynamic as this is daunting, from the first officer killed until the last, just 20 minutes passed and crime scenes were spread over a distance of almost a kilometer. The speed, danger and complexity of the incident as well as the later influx of resources required strong operational awareness, sound tactics and decisive command and control. *****.

Supervisory Training

Supervisory training is managed through NHQ. The national policy centre is supported by four Performance Centres located across the country, whose primary function is to coordinate, manage and deliver developmental programs:

Field Coaching Program (FCP)

Supervisor Development Program (SDP)

Manager Development Program (MDP)

Executive/Officer Development Program (EODP)

The SDP, which is intended for front line supervisors, provides nothing on tactical supervision or command and control.

The impact of IARD training on this incident has been discussed. It must be noted that while many General Duty first responders have received IARD training, it contains no supervisory component. In fact, none of the supervisors involved in the initial response had specific training or experience in supervising critical incidents.

The transition of command between the Operations NCO, OIC Operations for Codiac, and the Critical Incident Commander was problematic and not defined. Information was not well tracked and therefore not effectively shared. This problem was compounded each time command transitioned.

The supervisors involved in this incident were faced with circumstances very few will ever experience. While it is recognized the level of supervisory competence required in the first hour of this incident was extraordinary, police are routinely involved in managing crises and supervisors should have an ability to take charge.

3.3 It is recommended that the RCMP provide training to better prepare supervisors to manage and supervise throughout a critical incident until a CIC assumes command.

The Canadian Police College offers a five day training course that covers some of the principles necessary to manage events such as this. It is unreasonable to expect every supervisor to attend this course, so a more reasonable delivery mechanism should be established.

It should also be noted that while training is an important component in improving the competency around tactics and command, the RCMP must also ensure that it promotes a culture in support of such learning.

Command and Control

The greatest impediments to providing command and control during this incident was a lack of communication and poor situational awareness. Supervisors require information to direct and manage resources; members require it for tactical decision-making, risk assessments and safety. This information sharing did not always take place, hampering proper management of the incident at all levels.

Research on active shooting incidents found that when command and control is not formally established, the failure to share information across responder groups increases. This results in potential information gaps causing substantial delays in response. Delays subsequently stem from the lack of a common operating picture (COP) necessary to effectively manage available resources. The safety of first responders can also be compromised without clear communication regarding secure zones and the status of the shooter(s).

Situational Awareness

Situational awareness (SA) is essential to the planning and execution of emergency response efforts. In broad terms, SA is being aware of what is happening around you and understanding what that means to you now and in the future. Those working in critical environments, like those involved in this crisis are highly dependent on SA to make decisions and perform their duties. SA tools exist which enable access to knowledge, facilitate the sharing of information in real time, and assist in making strategic decisions and developing proactive solutions.

Common Operating Picture

While time did not permit a thorough review of existing technology that could have assisted in the coordination of this incident, the Review recommends the following:

3.4 The RCMP explore options that would allow for a common operating picture (COP) to be available for simultaneous monitoring by frontline supervisors, Critical Incident Command, Division Emergency Operations Center (DEOC) and the National Operations Center (NOC). *****.

3.5 That Emergency Management System and the 'web- mapping service from the NOC' be considered for each Division and policy, training and supervision be established requiring their use in Critical Incidents, Major Events and disasters, by DEOC and the CIC.

The "J" Division DEOC experienced capability issues. Situational awareness *****, no news media feeds within the facility, cramped quarters, lack of a dedicated communications room staffed by call takers and radio dispatchers who could manage and direct some of the information flow and no access to NOC's web- mapping service. The DEOC was not in a state of readiness when activated. Technical problems could have been avoided by having a maintenance schedule for DEOC equipment and the necessary resources to manage such a schedule.

The RCMP National Operations Centre was not activated. This impeded intergovernmental coordination and the efficiency and effectiveness of resource requests, *****.

*****.

3.6 It is recommended that, where it does not already exist, each Division establish a policy and protocol through an Emergency Operational Plan to identify entry/exit points and major transportation routes that should be alerted and monitored in the event of a relevant crisis.

Section 4: The Evolving Response

Question from the Commissioner: How was the evolving ERT/coordinated response managed?

General Duty members manage dangerous situations by responding to, containing and isolating the threat. Supervisors have the responsibility to take control and if needed, decide on whether to evacuate people from harm's way, have people shelter in place and put in place some reactionary plans for an escape or surrender.

It remained the responsibility of the general duty supervisors to manage this incident until command was taken over by a Critical Incident Commander (CIC). As the incident unfolded, it was described by some members as chaotic. Naturally confusion influenced the shooting phase of such a rapidly evolving and deadly incident. This section of the report examines the evolving response from the shootings to the large scale manhunt.

The RCMP has developed structures, strategies, plans and procedures to reduce risk in response to critical incidents. The command structures are scalable depending on the nature and scope of the incident. During a critical incident such as this one, the tactical level command on the ground is managed by an accredited CIC. For major events, national crises or incidents requiring centralized coordination, the Division CrOps may order additional staffing of the Divisional Emergency Operations Centre (DEOC) to coordinate RCMP resources and external partners. The CO/CrOps Officer retains control and authority for the operation.

RCMP National HQ, through the National Operations Centre (NOC), provides national policy guidance, manages and co-ordinates information and resources among the Divisions, sets strategic priorities and serves as the coordination and communication link with other federal government departments and agencies. The NOC operates 24 hours a day, seven days a week and performs both routine and crisis operations. During an emergency operation, liaison with foreign agencies, other federal departments and agencies, and Public Safety Canada should, at the national level, be conducted through the NOC.

The RCMP manages critical incidents by establishing critical incident response teams consisting of a CIC and two subordinate elements: the Emergency Response Team (ERT) and the Crisis Negotiation Team (CNT). By virtue of the CIC's authority, responsibility and accountability, this is the central leadership position to command the incident, including liaison with all support services. The CIC is responsible to direct the human and material resources required for a safe conclusion to the critical incident. The CIC is responsible for the deployment of resources, the interaction of those resources, and maintaining the integrity of the command triangle.

One of the first responsibilities of a CIC upon assuming command is to establish a "Mission Statement" that identifies and directs the strategic objective(s) of the police operation. In this case it was: "To locate and arrest Justin Bourque, keeping the safety of the public, police and subject in mind". Ultimately, the mission was successfully accomplished as Justin Bourque was arrested and there were no more casualties.

This section examines how effectively the RCMP carried out the search for Justin Bourque while simultaneously conducting the criminal investigation and maximizing both public and police safety. During the manhunt phase, there was a wide range of concurrent tactical and investigative police activities taking place, in close proximity to an armed police killer. Without knowing Bourque's location it was impossible to have a definitive perimeter and effective containment, thus all policing activities were extremely high-risk operations. The incident commanders, as well as all deployed specialized and regular police responders, were faced with the fact that Bourque still had significant tactical advantages; including the ability to fire upon police should he so choose.

In addition to actively searching for Bourque and developing tactical intervention options to deal with him once located, there were multiple crime scenes to examine as part of the ongoing criminal investigation into three murders and the attempted murders. These crime scenes were all near the last known location of the gunman. As such, ensuring the protection of investigative personnel attending these scenes was a prime concern. Additionally, there was the massive logistical burden of effectively equipping and deploying hundreds of RCMP members and police officers from various other agencies arriving from across Atlantic and Central Canada so that they were operationally prepared for the task at hand.

Within the broader context of the evolving response to this incident, particular attention will be paid to the following aspects:

The manner in which the activation and deployment of ERT from multiple divisions was coordinated and executed, and the overall efficiency of this process in terms of response time and mission readiness.

The effectiveness of RCMP Air Services and Transport Canada aircraft in supporting tactical operations on the ground during the protracted search for the suspect.

Tactical limitations due to training, equipment or policy/ procedures which had a direct impact on ERT operational effectiveness.

Tactical plans/strategies utilized during the operation;

Overall coordination of the entire operation to locate and apprehend the suspect.

Dissemination of relevant information to members in a timely manner via intelligence updates, briefings, direction, etc.

Logistics in support of the evolving response (e.g. accommodations, food, equipment, transportation, etc.)

Centralized organizational support to "J" Division during the incident.

After the murder of Cst. Larche, specialized resources began to arrive in the area. Supervisors and the CIC coming onto the scene were attempting to establish a clear picture of what occurred and what Codiac detachment was facing. The initial supervisors recognized the challenges of the size and geography of the area while they worked to establish containment of the killer.

The Review Team interviewed many members who responded to the detachment to await deployment. It was clear that despite the Ops NCO believing he was in charge, many members observed Commissioned Officers and senior NCOs in the office as well so were unclear about who was deploying members and who had the on-scene supervisory responsibility. In situations such as this, clear identification of the person in charge is essential otherwise there could be confusion and duplication of functions.

The Ops NCO was not advised that he was being replaced by a more senior member so he maintained control of his Command Post (CP) operation from the Watch Sgts.' office. As no formal 'hand-over' had occurred, he felt he was managing this aspect of the incident until a CIC arrived. Once an accredited CIC, arrived on scene, a Command Post was established at the Moncton Coliseum. It was quickly determined to be a poor location so the CP and staging area were subsequently moved to the Moncton Garrison. However, some members were not informed of this and continued to report to the Coliseum as a staging area. Adding to the confusion, there were cases where members self-deployed to the scene.

The critical incident CP was not operational until approximately 03:00 on June 5. Quickly establishing an operational command post and taking control of the management of such a high risk incident is essential. The first CIC, focused much of his attention during the evening of June 4 and early morning hours of June 5, setting up the CP at the Moncton Garrison, leaving the Ops NCO and Ops Officer at Codiac detachment, as the incident commanders, *****. The establishment of a suitable command post should have been delegated by the CIC while he focused upon carrying out his command role. The delay in establishing a command post should not have detracted from taking operational control.

Command post at the Moncton Garrison. Map inset shows location of CP in relation to lock down area, Moncton Coliseum, Codiac Detachment and the arrest location.

Once the appropriate level of command was in place at about 03:00. on June 5, the situation became more stable, information and intelligence began to flow, situational awareness was firmly established, and communication became more fluid. As ERTs arrived they were briefed and deployed to scene protection, tactical patrols and searches of areas where there had been reported sightings of Bourque. With the official CP established and properly staffed (however, without MCU representation), the numerous crime scenes were secured and scene processing began.

The CP at the Moncton Garrison was configured properly in that the CIC, CNT and ERT leaders were co-located. In order to successfully function efforts must be made to establish effective lines of communication within the triangle by utilizing liaison persons. The "J" Division ERT Leader maintained his liaison function with the CIC and developed (unwritten) tactical plans.

Command structures such as DEOC and NOC can be valuable tools in complicated incidents. In this incident the National Operations Centre was not activated. As a result, much of the national-level coordination occurred directly between CAP and Divisional CrOps offices. The coordination of resources between Divisions and with federal partners such as the Canadian Forces and Transport Canada should have been managed by the NOC's established standard operating procedures. These are well-developed and have been operationalized very effectively in previous incidents.

While the CICs described their use of Situation, Mission, Execution, Administration, Command (SMEAC), outlined their Mission Statement and authorities, specific operational plans were never documented. The reason provided for not documenting their tactical plans for each of the deployed tactical units was that the situation was too fluid and unfolding too quickly to write out plans. When it is not logistically feasible, or there is a lack of time to complete, tactical plans can be approved verbally by a CIC. However, a critical incident of 29 hours should provide time to write out specific operational plans for teams. In the absence of written operational plans, there was a lack of detail provided to some ERTs around how specific tactical operations would be executed. Further, had the situation resulted in a protracted trial or if a fatality inquest is called, the only documentation with respect to tactical planning would be the briefing boards/flip charts and CIC Scribe notes. This was a shortcoming and not in accordance with RCMP Policy and Training.

The CIC Scribe notes in this incident were similar to an ERT communications log of what was occurring as opposed to the notes of the CIC making critical decisions and the resultant tasking of employees to reach mission objectives. Strategies and options need to be created by the CIC in order to reach a decision and these should be captured by the Scribe and Boards. These are based on what the CIC knew at that time and these strategies can change based on circumstance and receipt of new information indicating that the situation has changed. Situational changes resulting in changes to strategy must be documented.

There were 100 tactical police officers deployed in response to this critical incident. Three of the four RCMP Atlantic Region Emergency Response Teams, as well those from "C" and National Division, were activated and deployed. Additionally, the municipal police forces of Bathurst, Miramichi, Fredericton and Saint John contributed their respective tactical teams to the operation.

Providing direct support to these teams were six scribes, four radio technicians, 14 Emergency Medical Response Team (EMRT) members, 11 Police Dog Service teams, EDU and Special "I" personnel. Additionally, there were five RCMP Tactical Armoured Vehicles (TAV) and aircraft from both RCMP Air Services (including chartered commercial carriers) and Transport Canada, providing tactical and logistical support.

Activation & Deployment of Emergency Response Teams

This segment will be examined in two distinct components; the activation and deployment of the "J" Division team, and the subsequent activation and deployment of teams from non-RCMP jurisdictions in New Brunswick and other RCMP teams. The RCMP ERT Program is intended to be scalable, whereby teams can operate independently to tactically respond to incidents that are determined to be within their capabilities, or can effectively integrate with other RCMP ERTs to form a larger response package to a critical incident that demands greater resources or capabilities than a single team can provide. Commonality of training, equipment, tactics and command structure enable this capability, and in practice teams regularly support one another on operations. The team leader of jurisdiction will generally take command of tactical operations under the direction of the CIC, and assume responsibility for coordinating the tactical activities of the deployed teams.

The request was made at 19:51 for the "J" Division ERT by the Ops NCO and the ERT leader was contacted via telephone by the OIC of Codiac detachment at 20:00. The initial information the ERT leader received was that an active shooter situation was unfolding, and two members had been shot.

Based on his initial phone conversation, the ERT leader was initially under the impression that the shooting was at the Hildegard school. As a result of this miscommunication, the team leader's initial fan-out message to the team made mention of a school being involved. The five "J" Division ERT members who live in the Moncton area were able to rapidly deploy, before the rest of their team arrived. As a result of the erroneous school information, *****. The information ERT members were receiving was subsequently corrected and the rest of the team members arrived dressed in their camouflage uniforms with equipment suited to the operation.

Specialized Crisis Negotiation Team (CNT) members were also deployed in support of this incident. The "J" Division CNT responded with a sufficient number of team members. Immediately upon activation, the CNT members proactively sought out critical information they would require. This is a common practice with RCMP CNT members and this approach greatly assists investigators and the command triangle. The "J" Division CNT worked quickly to develop a communication strategy in case contact was made with Bourque.

The CIC and the CNT appropriately engaged both Behaviour Sciences Group (BSG) and a Mental Health Professional (MHP) to assist in developing strategies for the safe arrest of Bourque. MHPs are able to assist the CNT with medical opinions and strategies for resolution of incidents. MHPs funnel their input through the CNT and do not have direct conversation with the CIC. As mentioned in this review, the CIC appropriately directed the CNT to contact a MHP. A review of the CNT material showed that the CNT was tasked appropriately and conducted an After Action Report which will improve on their response to these types of calls for service.

There was a coordinated approach between CNT and ERT with respect to how they would work together if Bourque was encountered. The CIC would have ensured that the ERT members were in place, ready to receive the suspect. Without written operational plans the Review Team does not know the approved tactical approach to Bourque if he was encountered. ERT members had discussions on their rules of engagement if Bourque was a threat to them, their tactical movements and their response to various other potential actions by Bourque. This is the type of command-and-control that is typically exercised during ERT activities. *****.

At this point, it is necessary to outline the procedure by which ERTs generally relieve general duty personnel at a scene. *****.

The Criminal Operations Officer in "J" Division contacted the Assistant Commissioner at Contract and Aboriginal Policing in Ottawa, in order to request his assistance in activating and deploying supporting teams. As discussed elsewhere, these activities would have been more appropriately conducted by "J" Division DEOC and NOC. Subsequently, the CrOps Officers in "C", "H", "L", "B" and "National" (Ottawa) Divisions were contacted to authorize deployments. The Ottawa team immediately began making preparations for an advance element to be transported by air, with the remainder to be deployed via ground transport. An Ottawa aviation company was contracted to transport eight National Division members in advance of the main body. As a result, this first group of members was airborne within two hours of first being activated.

The "C" Division team was in Quebec City at the time conducting marine operations training with "O" Division ERT and Quebec police agencies. Due to the high volume of calls the "C" Division team had been experiencing, they had brought much of their operational equipment on this exercise in case of a call out. This allowed them to respond directly to Moncton as they did not have to drive back to Montreal to get their gear; saving time and reducing fatigue. There was one "C" Division ERT member still in Montreal, and he was directed to gather additional tactical equipment and prepare it for airlift out of Montreal, via RCMP air services, the following morning. The "C" Division team drove overnight from Quebec City. When they arrived in Moncton, they had been up for nearly 24 hours already. They were therefore told by Sgt. Welcher to get rest at a local hotel before deploying. The "O" Division team did not have the necessary operational equipment in Quebec City, so were unable to deploy to Moncton.

The "C" Division Tactical Armoured Vehicle (TAV) was not deployed on this call, as it was back in Montreal and had not been requested. There were a total of five RCMP TAV-1s deployed to this call for ERT use, specifically two from National, and one from each of "J", "H" and the National Armour Systems unit in Ottawa. Had he been aware of the tactical situation, the "C" Division Team Leader would have ensured that his TAV was supplied, and requested that the Quebec City police armoured vehicle also be made available. The RCMP TAV was designed for this type of operation and, given the scale of this incident, having as many as possible was essential. To mitigate the shortage of TAVs, commercial armoured trucks were put into use.

*****. The "H" Division vehicle ***** did break down. It had to be towed but a mechanic was able to fix it.

4.1 It is recommended that when transporting TAVs long distances it should be done by rail or flatbed truck.

Effectiveness of ERT Training, Tactics and Equipment and How ERT was Utilized During this Incident

ERT operates as one element of an integrated critical incident response package. ERT members are designated to make contact with a suspect on the ground and take him/her into custody. To accomplish this effectively requires the collaborative efforts of many supporting elements, such as General Duty, Special "I", Air Services, Crisis Negotiators, and a host of others. The ability of ERT to successfully inter-operate with these groups is crucial to successfully accomplish the mission. This inter-operability hinges directly on the training, tactics and equipment at the teams' disposal.

There were no identified issues with the mission profiles established for tactical personnel during this incident. All fell within the ERT operational mandate. The RCMP Tactical Operations Manual (T.O.M.) chapter 2.3 identifies a list of possible duties for which an ERT can provide tactical armed support, and for the purposes of this incident the following were applicable/possible:

Apprehending or neutralizing armed/barricaded persons with or without hostages;

Assisting in the arrest of suspects or mentally deranged persons;

Assisting other sections as required;

High risk vehicle take downs or arrests;

Conducing rural surveillance where compromise could result in violence towards police, or when specialized equipment and training are required due to environmental conditions.

The critical advantage an ERT provides to an incident commander is the ability to develop plans to accomplish a particular mission in light of the tactical situation and to coordinate the efforts of one or many teams. Tactical situations are constantly changing and, as such, the training and tactics of the team are designed to allow flexibility. Tactics, however, *****.

ERT was tasked with several missions during this incident. Since the whereabouts of the suspect were unknown, ERT assets were assembled into reactive Immediate Action (IA) teams, mounted aboard TAVs, to respond to reported sightings of the suspect and assess the situation quickly. In these circumstances, a hasty plan would be formed, and multiple IA teams and vehicles deployed in a coordinated fashion based on each situation. This was assuming the sighting was in an urban or open area *****. If surveillance aircraft reported a possible sighting, ERT elements would be directed to the location and deployed appropriately based on real-time aerial surveillance. The fundamental tactical principle of "Isolate – Contain – Evacuate – Negotiate" could not be applied until the suspect was found. Social media, aircraft, electronic and human surveillance of persons of interest, and responses to reported sightings were all employed to locate Bourque so that ERT could apprehend or, if required, neutralize him. Given the high risk of conducting a ground search for the suspect when his location was unknown, this option was deemed a last-resort by Incident Command in consultation with the Tactical Operations Advisor (TOA).

ERT members also provided security at the various crime scenes that had to be processed while the search was ongoing, with the suspect potentially nearby. ERTs formed protective perimeters around each scene as it was being processed. *****. Their assistance enabled ERT resources to be deployed where their broader range of tactical capabilities could be best used.

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In the past, an ERT would enter wooded or poorly-lit areas with only a PDS team and their eyes and ears as the only means of detecting an armed suspect. *****.

ERT personnel need to have the proper equipment and training to maximize the tactical advantage *****.

*****.

Many ERT deployments take place at night *****.

4.4 It is recommended that annual night training exercises with Air Services be developed and undertaken to maintain proficiency for ERT members.

Use of the Tactical Armoured Vehicles

The TAVs were also critical assets, and this was the type of incident precisely for which it was developed. ERT members carry equipment which reduces their mobility. *****. Any economy of movement through strategic positioning of members that can save energy pays dividends. TAVs provide the ability to move members close to the threat while protecting them from gunfire and giving them the ability to return fire. They are both a major tactical advantage and a deterrent that could encourage surrender. In terms of ballistic protection, the TAV was excellent, but there were problems with TAV tactics and support that were highlighted during this event.

Positioning the TAVs and ascertaining which vehicle carried which team was complicated by the fact that incident command was relying on *****. During the arrest, multiple TAVs were deployed in an effort to contain the suspect. *****.

4.5 It is recommended that infrared (IR) strobes be attached to each TAV to enable them to be identified by specific call-sign during operations with air surveillance.

TAV driver training is currently limited to ERT members. *****. There needs to be adequate redundancy of TAV drivers. This is done in other areas of the program *****.

4.6 It is recommended that non-ERT personnel be selected and trained as drivers for TAVs to free up ERT members for primary duties.

In addition to the formal training provided for TAV operators, ERT members need training to ensure they are optimally using the vehicle's capabilities. On the centralized ERT course, candidates are taught basic tactics and procedures related to TAV operations, but ERT members in the field do not receive this training. Some Divisional teams have developed their own SOPs and shared these with TTS for incorporation into national, shared SOPs. When multiple teams are deployed with TAVs, and where members from different teams are in the same vehicle, it is critical that a common level of familiarity with the vehicle exists.

*****.

The concept of the TAV in ERT use is sound *****. The RCMP is the only user of this vehicle as it was built to our specifications instead of being procured "off-the-shelf". One of the main reasons for this is that the vehicle is designed to offer a higher level of ballistic protection than commercially-available alternatives. As this was a limited production, custom vehicle, manufacturer support is minimal.

Standardization of Equipment and Training Across the ERT Program

While this report is not a review of the RCMP ERT program, there are features of the program that affect operations when multiple teams are required to operate collectively. There is much similarity between teams in terms of basic equipment, training and tactics but there are also significant differences. There are full-time teams, part-time teams, and teams composed of a blend of full and part-time members.

Reports over the years have detailed the need for ERT to be a full-time duty function, so that all ERT members can devote the time necessary to developing and maintaining highly-perishable skills. For this reason, the Review Team supports the concept of full time teams. However, the fiscal and human resources of each Division determine, in large part, what type of team each jurisdiction can attain. It is important to focus on improvements that are attainable given a Division's resources.

All teams should have access to the same equipment to allow for inter- operability. For the CIC model to function optimally, incident commanders must be both aware of, and confident in, the capabilities of the ERT(s) under their authority. *****. This applies not only to technical devices *****, but also to seemingly less significant items such as uniforms. In Moncton, the suspect was known to be wearing a camouflage uniform. There is a danger in having teams wear camouflage uniforms ***** as they will not be instantly identifiable as belonging to the police. A delay in positively identifying a member versus an aggressor, based on their clothing, could prove fatal in a close-combat situation. Whereas local vegetation dictates what type/pattern of camouflage clothing is most effective for individual teams, collective rural and urban standards would be advantageous when teams work together.

An ERT assaulter in British Columbia should be in possession of the same kit items as one in Newfoundland, if the teams are to assume identical mission profiles. The same is true of sniper/observers. This would allow tactics to also be standardized to the extent possible. In incidents such as this one, it is important for incident commanders to have teams with very similar capabilities, to reduce the need to tailor missions to the unique limitations of each team.

4.7 It is recommended that a standard list of equipment be developed for ERT duties and that this equipment be acquired and distributed across the program.

Utilization and Effectiveness of RCMP Air Services and Transport Canada Aircraft During the Operation

Aircraft were a key support during the evolving response to this incident. The risk members were exposed to in locating and apprehending Bourque was greatly reduced because of aerial surveillance. Given the large area to be searched, and the extreme risk that such a search operation would have involved were it conducted by personnel on the ground, specially-equipped aircraft were the most effective means of accomplishing the task. Additionally, RCMP Air Services' fleet (augmented by contracted charter aircraft) provided an airlift capability for both personnel and equipment that directly contributed to the rapid deployment of resources on site.

The scheduling and coordination of aircraft use during this incident was a challenge. Aircraft were being deployed as passenger and equipment transports and as tactical assets to assist in the search for Bourque. One of the principal issues identified was the fact that although air services was an essential support element to incident command, there was no air services liaison embedded within the command post. A liaison would have been able to offer advice to the incident commander and, with air services management, deploy aircraft to meet the needs of the operation while simultaneously ensuring that equipment and personnel were used in an effective and coordinated manner. In future instances where Air Services is required to play such a large role in an operation, it is recommended that a representative be included in the command structure overseeing the incident, much as ERT, Major Crimes, Negotiators, etc. are currently represented. To further maximize their ability to function in this role, the designated individuals should receive some form of incident command training to ensure they are able to work effectively in this environment (e.g. ICS training).

4.8 It is recommended in large scale events where Air Services is utilized, Air Services personnel with the appropriate training should be assigned to the Command Post as a liaison for air service support.

Soon after the initial call for ERT support had been received, air services were part of the response to this incident. The helicopter based in Moncton, *****, took to the air after the OCC advised the pilot that a member had been shot. The pilot was accompanied by a general-duty member *****. The pilot provided "on-the-job" training to this member in order to make use of the equipment.

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With respect to the ***** system itself, the model carried by the helicopter is older technology ***** the helicopter was airborne quickly and was able to provide an aerial surveillance capability for members on scene.RCMP Air Services was able to contract a private charter company to furnish a jet to transport the initial group of eight fully-equipped National Division ERT members from Ottawa to Moncton. In total this aircraft made three return trips ferrying personnel and equipment. The standing offer the RCMP had in place with the charter company made the rapid contracting possible. The Citation jet used allowed for a combination of personnel and equipment to be transported faster than any RCMP aircraft could. An RCMP aircraft (one that was not equipped for search operations) was dispatched to pick up "J" Division senior managers from meetings outside of New Brunswick, and an additional RCMP aircraft was deployed from London, Ontario to deliver HBA and carbines from Ottawa to Moncton to support the operation. A Montreal- based aircraft was used to deliver additional ERT equipment to the "C" Division team.

Perimeter Security

This aspect of the ongoing police operation once contact with Bourque was lost proved challenging to manage. A number of factors resulted in members who were stationed at perimeter locations being extremely vulnerable. Some of these risks were direct consequences of the threat Bourque posed, and others resulted from the general state of confusion which existed in relation to how the deployment of personnel was being directed

The most significant tactical reality that the CIC had to contend with in terms of how members were deployed, was that Bourque's whereabouts were completely unknown. This refers not only to his exact location, but to where he was in the most general sense. In the absence of reliable intelligence, the best that could be done was to make an educated assumption as to where he could be. For all intents and purposes, the working perimeter was Greater Moncton.

The CIC deployed all available technological and human means to try and narrow down the area where Bourque could be hiding. These included *****, the continuous monitoring of social media, *****, and community vigilance in reporting suspicious activity. There were several reports of suspected sightings and gunfire during the period between Bourque's initial evasion and his ultimate arrest, at different locations across town, with each one requiring a robust police response. As such, it can be safely stated that the perimeter was fluid as opposed to static by necessity.

In the immediate aftermath of the shootings, off-duty Codiac detachment members began arriving at the office to assist. Progressively, more and more resources arrived from other parts of the province and other Divisions. The number of arriving members was significant, but an effective reception and briefing process had not been established. Codiac detachment was the default staging area for arriving personnel, many of whom simply arrived and organized themselves as best they could in terms of obtaining information and equipment before deploying. The process of documenting who was arriving, which vehicles they were assigned to, where they were going and what their specific role(s) were can only be described as chaotic. This sentiment was consistently expressed by members with whom the Review Team spoke. It ultimately led to difficulty in coordinating the perimeter, as it could not be accurately determined who was where.

The OCC was faced with the huge challenge of trying to sort out which vehicles were on the road, and who was in the vehicles. All available Codiac vehicles, marked and unmarked, were being used. Members from other divisions arrived in vehicles whose CIIDS GPS mapping capability was ineffective because the software was not programmed for "J" Division. This meant OCC could not track their location or movement. One of the principal requirements a CIC must be aware of upon taking tactical control of an incident is an appreciation of where and how many of his/her resources are deployed. Several hours ultimately elapsed before this was achieved. An example of the confusion that reigned is the fact that Cst. Martine Benoit, who had been shot at repeatedly by Bourque while she took cover in her police vehicle during the initial incident, was subsequently re-deployed as perimeter security without being debriefed or provided care.

Assistance from members, who had been on the Carbine Operator and Carbine Operator Trainer courses in Fredericton at the time of the incident, was requested. There was a need for enhanced firepower at the first-responder level which these members could provide, since they were capable of operating the carbine. All ***** of the serviceable detachment shotguns were deployed with perimeter members, as well as the ***** detachment rifles on inventory. *****. They were nevertheless pressed into service to provide some type of long gun capability to front-line members.

Media images were broadcast both domestically and internationally which depicted uniformed members at various locations in Moncton performing perimeter security duties. Very few showed RCMP officers wearing HBA. Some of this can be attributed to the fact that the police vehicles at Codiac were equipped with ***** of HBA *****, but most cars *****, and as such there were not enough to go around. Many members had no idea that HBA was even in the vehicle, and others were not familiar with how to wear the equipment properly. This all speaks to a general lack of knowledge and understanding with respect to how and when HBA must be worn.

A number of members were observed to be either sitting in or standing beside their vehicles while on perimeter duty. As was tragically evidenced during this incident, the occupant(s) of a police vehicle are relatively easy targets for an armed assailant such as Bourque. It can represent effective cover if a member positions him/herself properly in relation to it. That being said, the Review Team acknowledges that it is extremely difficult to remain hyper-vigilant for extended periods of time under these conditions. The options available to members were limited in terms of what level of self-protection they could employ. These included being armed with long-barrelled firearms capable of engaging a threat from distance, wearing enhanced ballistic protection in the form of HBA, and ensuring they were mobile and not sitting in a vehicle should they have to return fire if engaged in a gun battle.

In reviewing Bourque's statement, the Review Team was able to extract some common themes. He only engaged police in situations where he felt he had an overwhelming tactical advantage. He was aware of the police presence during the manhunt for him, but elected not to engage in further gunfights because he felt the odds were not in his favour. He specified that the number of officers he observed at any given location was a determining factor for him. If there were several members he felt he would be overmatched and ultimately lose the confrontation. Members deployed in groups on perimeter duty were a deterrent for Bourque.

In summary, although perimeter security duties are a fairly common police function, there is a need to ensure members are able to apply appropriate tactics based on the nature of the incident. This includes making sure they have the necessary equipment for the role they are performing, and that supervisors impress upon them the tactical considerations they need to consider in view of the circumstances.

Arrest of Justin Bourque

The areas highlighted in this section including ERT, Air Services, TAVs, CIC etc., all played a role in the arrest of Justin Bourque, which is described in detail below.

The locating of the suspect, and his subsequent apprehension by ERT members, involved the use of both highly sophisticated electronic surveillance equipment, and basic, low-tech, eyewitness observations. This section will examine how the suspect was located, the tactics employed to approach his location, and the difficulties experienced in coordinating the deployment and movement of ERT resources (members and vehicles) as a result of some technical capabilities that were lacking. Although the suspect was successfully apprehended without further casualties, there were tactical errors made, in large part due to the aforementioned equipment issues. This could have led to a significantly more violent end to this incident. This is not intended to be critical of the members who participated as they were operating in the best manner possible with the intelligence and equipment at their disposal. The intent is to highlight where improvements can be made to address these shortcomings within the ERT program in the future.

The sequence of events which led to the suspect ultimately being located began with the report of a possible sighting from an eyewitness who resided on Mecca Drive. The witness described seeing a male subject crouched down outside, below the kitchen window of the residence, wearing a camouflage jacket and brown pants. The subject then ran back into the wooded area behind the house. This information was passed on to police and, as a result, ERT members (aboard TAVs) were deployed to the area to investigate. Additionally, aircraft were deployed overhead ***** facilitate an effective tactical approach by ERT members, taking full advantage of the terrain and maximizing public and police safety during this high-risk phase of the potential arrest operation. *****, based on the sighting of the suspicious person, the search operations were concentrated in the area of Mecca Drive.

As was mentioned in the segment of this report detailing some of the equipment issues air services aircraft encountered, the ***** RCMP helicopter was using a camera which is considered to be older technology than that which is currently available. *****.

The suspect was not interviewed by the Review Team, so it is impossible to obtain a confirmation of what he perceived during the time frame preceding his arrest. However, based on a number of factors, including video footage, some reasonable assumptions can be made as to why the suspect did what he did, when he did it. *****. Basically, he knew the helicopter was there and was trying to hide from it. *****.

The movement of ERT personnel on the ground was coordinated from the CP in an attempt to isolate and contain the suspect. ***** team, consisting of the Saint John Police Force ERT and three members of the "L" Division RCMP ERT, travelled in their TAV to Mecca Drive, dismounted from the vehicle *****

*****.

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From the point of last contact with Bourque until his eventual apprehension 29 hours later, there were no more casualties (including the suspect). This fact represents the successful realization of the police mission. All members involved deserve enormous credit for this result. It should be noted that Bourque did not just give up and walk out of hiding at the time and place of his own choosing. He surrendered once he realized that he faced overwhelming force and was unwilling to die in a gun battle he could not win.

Military Assistance

Provisions exist for the RCMP to request the assistance of the Canadian Armed Forces (CF) in operations where specialized or unique capabilities are required. This can also extend to the use of specialized equipment in possession of the CF. In relation to this incident there were several areas where this may have applied.

Armoured vehicles were obtained from Brinks until RCMP TAVs could be deployed on scene. With a large military presence at CFB Gagetown it is highly likely they would have had armoured vehicles and drivers available who could deploy to Moncton on short notice to assist in supplementing the RCMP TAVs.

The CF also possesses aircraft and ground trackers who may have been able to assist both in the early stages or if the matter was prolonged.

The use of the Canadian Forces is strictly in an assistance capacity with the RCMP maintaining control of the operation and should be considered in these types of situations.

Section 5: Equipment and Weapons

Question from the Commissioner: What was the state of availability of equipment and weapons and were they being used?

Responding Members

Twenty-four RCMP officers responded from the time of the initial call on June 4, 2014, of a suspicious person with a gun on Pioneer Avenue up to the point when the last shots were fired. Eighteen of these members were wearing Service Order No. 1 (working uniform), including soft body armour (SBA) and a fully-loaded pistol in a holster along with two loaded magazines. Four others responded in plain clothes wearing SBA with three of them armed with shotguns. One responded wearing PDS uniform with SBA and a fully-loaded pistol in a holster, and one in standard Forensic Identification Section (FIS) uniform with SBA and a fully-loaded pistol in a holster.

Firearms

Codiac detachment had ***** functioning shotguns and *****.308 rifles. Shotguns were issued to each of the two detachment dog handlers. ***** shotguns and *****.308 rifles were kept in a locked gun cabinet *****. There were approximately ***** shotgun shells and *****.308 cartridges kept with these weapons. The remaining shotguns and the detachment's ammunition stockpile were kept *****.

Codiac detachment has a commissionaire who issues equipment, including the shotguns and rifles, to members coming on shift. This is normally recorded on a sign out sheet. Hours of work for the commissionaire are 07:30 to 19:30, seven days a week. When this commissionaire is not on shift the cell block commissionaire issues the equipment.

At the time of the initial call no shotguns or rifles were deployed. Prior to this incident, it was uncommon for Codiac members to sign out shotguns at the start of their shifts. The practice of keeping the majority of the shotguns locked away ***** was likely influenced by the low demand for them. Codiac now keeps all shotguns and rifles ***** where members have ready access.

The June 4, sign out sheet shows that Cst. Martel, who responded as a backup before shots were fired, took a shotgun. At 20:00, the four plain clothes members returned to the detachment for the ***** shotguns ***** before going to the scene. *****.

An employee was called in at approximately 20:30 to assist in issuing weapons and other equipment. All detachment firearms were eventually deployed that night. One member reported deploying to the scene with the last ***** available shotgun cartridges.

The detachment's .308 rifles *****. When it became clear that the SOC was heavily armed, one off-duty member offered to bring his scoped hunting rifle to the scene and did so, as allowed by RCMP Operational Manual 4.3.4.

*****.

Shotgun and Rifle Capabilities

It is important to outline the functionality and limitations of the issue Remington 870 shotgun. The shotgun with issued buckshot is not intended to be employed as a precision-fire weapon at a target beyond 25m. It can be effective at greater distances, but RCMP training only goes to 25m. As the spread pattern of shot increases with distance, so does the risk of having pellets miss the intended target. Members are taught that at 25m, the spread pattern from RCMP-issued 00 buckshot (low recoil, 8 or 9 pellets) is roughly the width of a man's torso. Beyond 25m, progressively fewer shot pellets will hit the intended target and progressively more will miss. While several pieces of buckshot to the torso will often cause rapid incapacitation, each projectile that misses can be lethal to someone well beyond the intended target.

The shotgun's buckshot is capable of having a devastating impact on an aggressor as multiple .32" pellets transfer their energy into the body simultaneously, over a broad surface area. It is akin to being hit with several pistol rounds at the same time. Within range, shotguns offer excellent incapacitation potential. Furthermore, given the shape of these lead pellets the risk of over-penetration is low.

***** shotgun slugs was available to the members. Shotgun slugs provide greater accuracy as they are single, more aerodynamic projectiles. RCMP shotgun barrels are smoothbore for optimal use of buckshot. Without barrel rifling, even rifled slugs are less stable in flight, unlike the inherently more accurate rifle or pistol bullet. Although a slug would have permitted a longer-range shot (potentially 50-75m according to the RCMP Senior Armourer), the potential danger of an errant slug in a residential area would be much greater than that of a missed buckshot. Each buckshot pellet only has about 1/8 the energy of a slug and loses energy more quickly with distance. The shotgun is inherently less precise and has shorter range than a rifle.

Many members are not very comfortable with the shotgun and those who qualify with it *****.

Detachment rifles (Winchester .308 bolt-action model 70 in the case of Codiac) and the patrol carbine offer the ability to accurately strike targets at distances far greater than either the shotgun or pistol. The detachment rifle has a telescopic sight to facilitate aiming and identification of a target, whereas the standard configuration of the carbine includes *****. This is in keeping with the ***** maximum range at which the carbine is intended to be used by the RCMP.

Annual qualification with detachment rifles is no longer required and very few of the first responders had qualified with it.

The detachment rifle is slower to fire (shot to shot) than the patrol carbine and only has a *****. While the cartridge of the carbine has about half the power of the detachment rifle, it offers a much higher rate of fire and a ***** magazine which can be quickly replaced when empty. The RCMP configuration of the shotgun can be loaded with a maximum of ***** shells and offers a rate of fire between that of the carbine and the detachment rifle.

The member's personal rifle which was brought to the scene, as mentioned above, would have been functionally comparable to the detachment rifle and he presumably would have been comfortable in its use.

Patrol Carbine

Codiac did not have any general duty members trained as carbine users on June 4. In fact, Codiac detachment had acquired ***** C8 Patrol Carbines; however, these and several Codiac members were at CFB Gagetown for "J" Division's first carbine training course as this incident was unfolding. Had carbines been on site, there were several members with previous Canadian Forces training on the military version of this rifle who could have deployed them under RCMP Operational Manual 4.3.4. which states:

Based upon a continuous risk assessment in accordance with the principles of the Incident Management Intervention Model (IMIM), members may use other firearms at their disposal when their RCMP-issued firearms are inadequate for the situation, provided the member is able to safely handle the firearm to be used.

Given that many interviewed members stated that had the patrol carbine been available it would have made a positive difference in this incident, it was important to examine how the carbine might have influenced the circumstances at several key stages.

Cst. Daigle's First Visual

Cst. Daigle was the first member to have visual contact with the suspect in the wooded area near Bromfield. Bourque was approximately 70-80 meters away acting as though he was hunting. The carbine with its optical sight would have provided Cst. Daigle with better tactical options. He could have more effectively utilized ***** while attempting verbal intervention. The shotgun or detachment rifle would also have been an appropriate option in this situation.

First Contact – 15 Bromfield

Cst. Daigle stated that a member with a carbine in this situation could have more effectively maintained ***** of the suspect while verbal intervention was used. The suspect's response could have elicited the use of lethal force by the member providing ***** from either side of 15 Bromfield.

Cst. Dave Ross's Approach

When Cst. Ross spotted Bourque he evidently felt it best to close the distance as quickly as possible and attempt to engage the SOC. Ross drew his service pistol and fired two rounds through his windshield towards Bourque. He was using lethal force as Bourque was firing at him. It is also possible that he may have been attempting to use his vehicle to stop Bourque. If a member at the corner of Bromfield and Mailhot had seen Bourque shooting at Ross, it might have been possible to engage him with a carbine; although the distance was 100m beyond what members are being taught is the effective range of the carbine. Armed with a carbine, Ross may have elected to close to within effective range and tactically position his vehicle to engage Bourque. The 250m distance would have been within the effective range of the .308 rifle, if a member had taken a rifle to the scene.

Cst. Eric White's Visual

Cst. White may also have had an opportunity to use lethal force when he observed the suspect approximately 90 meters away on Mailhot Avenue. (Note: in White's statement, he indicated he felt Bourque was 50 feet away, however, the measured distance was actually much greater). He sought cover behind the PDS vehicle, but stated he might have been able to effectively use lethal force with a carbine. Based on his risk assessment, he was too far from the gunman to be able to obtain a proper pistol sight picture before getting shot.

Cst. Eric Dubois' Visual

Cst. Dubois stated he may have been able to take a shot at Bourque if he had a carbine. Dubois saw Bourque run across Hildegard while he was taking cover behind his vehicle. The distance would have been 100-150m and Bourque would have crossed an open area which was 10-15m wide from Dubois' perspective. A successful shot with a carbine would have been feasible but unlikely with the pistol.

Cst. Doug Larche's Engagement

Cst. Larche had his shotgun in hand when he was first fired upon and wounded by Bourque. It is not known at this time if the injuries that apparently prevented Larche from using the shotgun would have also prevented use of the carbine. As the carbine has less recoil, is semi- automatic and doesn't require manual pumping of the action for each shot, it may have been easier to use despite an upper body injury. Cst. Larche was able to draw and repeatedly fire his pistol.

Carbine Conclusion

The patrol carbines would have given a more effective lethal force option and could possibly have influenced members' risk assessments, tactical approach and confidence levels. This firearm was approved specifically to address this type of call.

Hard Body Armour

While the location of members' wounds suggests that Hard Body Armour (HBA) would not have saved lives or reduced the severity of wounds in this incident, the use of HBA is nonetheless an important issue. On June 4, Codiac detachment had ***** HBA in all but ***** cars. *****, this was a problem. The Review Team learned through interviews that one member opted to go without HBA so that her colleague, who had children, could have the protection of HBA. Members should never be in the position of having to decide who gets to wear the HBA.

A total of ***** HBA were available in Codiac, ***** in marked patrol vehicles and ***** individually issued to the Codiac members of the Strategic Tactical Operations Team (formerly Tactical Troop). All but ***** Codiac patrol vehicles (general duty and traffic) had ***** HBA *****. The Southeast District office, which sent members as backup, had a total of ***** HBA for ***** patrol vehicles. Some were kept in an equipment room and some in the patrol vehicles.

None of the uniformed members who responded in the early stages of this incident wore HBA to the scene. *****, nor is there a surplus at the detachment, thus the four plain clothes members who responded did not have HBA. Cst. Goguen (Southeast District) stated that she would have put her HBA on had she been given better information. Cst. Robertson (Southeast District), who was near the scene when he was dispatched, did not have time to return to the Southeast District office to obtain HBA.

RCMP policy on HBA, Operational Manual section 4.1.1, states a member is to "Apply the principles of the Incident Management Intervention Model (IMIM) in [their] continuous risk assessment and decision to wear Hard Body Armour". Thus, ultimately, it is left to the discretion of the member. HBA policy further provides "examples of incidents where HBA should be worn", leaving it to the individual risk assessment of the member. Examples "may include but are not limited to: firearm related calls, high risk vehicle stops, searches, road blocks, and containment situations".

After initially electing not to wear HBA, a report of shots fired should have significantly elevated members' risk assessments. Most of the members involved in the early response recognized the heightened risk but knew that, even if feasible, *****. They opted to carry on trying to engage the suspect who was armed and dangerous in a busy neighbourhood. While this was an appropriate and courageous decision, it illustrates the importance of early recognition of the need to wear HBA. Once shots were fired it was simply too late to get HBA. The issue of supervisors not directing responding members to use HBA is dealt with in the supervision section.

Despite having been issued in 2013, some members lacked familiarity with the relatively new HBA and carrier. It is important that members know the capabilities and limitations of the HBA and wear the vest properly to maximize its ballistic properties. The Review Team was told that some of the HBA was still in its original packaging, never having been tried on. There was at least one case where poorly worn HBA caused the loss of a member's spare pistol magazine.

Uniform

While the yellow stripe on the uniform pants may be helpful in establishing officer presence, it may also be a tactical disadvantage in some environments. Many residents, who were witnesses around the wooded area where contact was first made with the SOC, commented on the high visibility of the yellow stripes through the woods. Bourque did not mention it in his statement, nor was he asked about it, but it may have contributed to a tactical disadvantage while approaching the SOC in the woods.

The issue of the contrast between uniform shirts and Soft Body Armour external carrier colours has been raised with the Review Team. The SBA external carrier is a dark blue and the uniformed shirt is a light grey. This contrast may put members' safety at risk as the external vest is clearly visible to a potential aggressor, which in turn could expose where a member is not protected. The solution to this would be to make the uniformed shirt a dark colour to eliminate the contrast.

Overall Confidence of Responding Members

While the broadcast during the incident that, "we're outgunned" was largely true, that does not equate to members being helpless. In discussion with members and in reviewing various training material, *****. Depot firearms training used to include shooting the service revolver from 100 meters as an illustration of both the effectiveness and the limitations of these firearms. In the absence of rifles, the pistol or shotgun are still effective options beyond 25 meters, if appropriate shooting techniques, ammunition and tactics are used. RCMP annual firearms qualification and statements made in the carbine online course, regarding the limitations of the shotgun and pistol, *****. This will be discussed in more depth in the training section of this report.

Recommendations

5.1 Policy should be amended to state that where a general duty member is qualified in the use of a long barreled weapon and where one is available; the member must ensure the weapon is in the police vehicle while on duty.

5.2 Firearms must be stored with sufficient ammunition.

5.3 All RCMP members receive a briefing and demonstration on the appropriate deployment of HBA.

5.4 Shotguns should be fitted with slings to enhance their deployment and safety.

5.5 Maintenance and storage procedures of all detachment firearms and ammunition must be the subject of a mandatory ULQA.

Section 6: Member Training and Officer Safety Skills

Question from the Commissioner: Are there any identified gaps in existing training for our members? Are there new training requirements that can reasonably be placed on the RCMP by this event?

In order to study the tactical approach taken by the members in responding to this incident it is necessary to understand what training is offered by the RCMP both at Depot and In-service.

The Review Team sent a member to Depot to meet with key personnel and observe Depot training. It was learned that basic training at Depot does not present cadets with scenarios that offer the degree of risk members' experienced on June 4, 2014.

At Depot, cadets are instructed to rely on their observations with respect to threat cues, and then use the ***** stages of risk assessment and ***** tactical principles to manage any incident they may face. Cadets also learn the ***** tactical errors and the 4 C's of high stress situations:

Combat breathing (deep breath in for four seconds, hold for one and out for four).

The perception of risk by each member varies and can influence critical decisions such as; 'to move', 'where to move' and 'what specific actions to take in a given situation'.

Cadets are trained in the use of their duty pistol, the shotgun, and the other intervention options carried on their duty belt. This is achieved through a process that begins with lectures, follows with safety and practical manipulation and culminates in full use scenarios. Cadets must show proper risk assessment and use of the correct response during tactical training.

Scenarios generally begin by determining which use of force option is the correct one. As an example, in the gym, on the mats, a cadet can expect to encounter a scenario which requires a physical response. Once the basics are completed the scenarios expand to incorporate more decision making. This includes incorporating other use of force options and other intervention options into their assessment of risk. This scenario based training culminates with work at a mock detachment.

Once a member graduates and is in the field, use of force training can become segmented. The RCMP requires yearly qualification with the pistol and shotgun and re-qualification on other intervention options every three years. Additional tactical training not given at Depot is usually first encountered by frontline members during the RCMP Immediate Action Rapid Deployment (IARD) training. During most of this training, as in the early Depot scenarios, members know which intervention option they are expected to use based on the re- certification they are attending. In addition, firearm qualifications review gun safety and shooting fundamentals not tactics.

The annual RCMP firearms qualifications (pistol and shotgun) are done from a standing start and only include very minimal movement after shooting. This side step exercise completed after firing at the target was only added to the course of fire after recommendations from another report into the deaths of RCMP members. This is a bare minimum addition and inadequate to meet the requirement for movement. The qualification system is based on shooting a required score on a large stationary silhouette target, within a time limit. It is designed to ensure the candidate and the RCMP has met a minimum standard of proficiency and due diligence. This is technically not training and instead a test to determine if the candidate can hit a target in a specified time. To have confidence in your ability to hit targets at long range, after physical exertion, and while moving requires extensive training and ongoing practice. During the shooting incident in Moncton, members acted and reacted based on a number of factors, including their tactical training (Depot and IARD).

The initial response to the complaint of an SOC with two long guns revealed a disconnect between how gun calls are perceived by the individual versus what policy states. For example, ***** is in accordance with gun calls being high risk, as per RCMP policy and the IMIM. However, some of the members attending stated, "we get these calls all of the time." Gun calls in Moncton are common and frequently involve individuals with paintball or air guns or hunters. In the majority of these cases, police determine there is no real threat to public safety. While training teaches that these are high risk calls, experience feeds into cognitive biases which lead to the discounting of risk. The lack of shotguns and worn HBA in the initial response is indicative that experience had undermined training regarding individual risk assessments.

6.1 It is recommended that trainers and supervisors take into account how cognitive biases undermine training and consider how to mitigate the effect of these natural and universal thought processes.

Many responding members felt the pistol was an insufficient intervention option in this incident. RCMP Tactical Training Section indicated that the effective range of the pistol and ammunition is beyond 100 metres, in the hands of a skilled shooter. In almost all of the encounters between the members and Justin Bourque the pistol was not the best option but it was potentially a viable option.

The surveillance video from Bromfield Court shows some members performing in a way that would indicate they were tactically unaware of the gravity of the situation, given that rounds had just been fired in their vicinity. Not all had drawn their pistols and one was carrying the shotgun over his shoulder instead of in the low ready position. The marksmanship testing approach to pistol and shotgun qualifications may contribute to the perception of a short effective range and many members feeling they are not proficient enough to succeed in a dynamic, or longer distance exchange of gunfire. Additionally, during the response to a sighting of the shooter later that night, a shotgun was accidentally discharged. The member was running with the safety off, with the barrel pointing at the ground. After bumping a police vehicle a round was discharged. As mentioned, the yearly qualifications do not require members to run, re-acquire targets, transition, and think while shooting. This may have contributed to these examples of firearms being handled in a non-tactical manner.

6.2 It is recommended that any testing component of RCMP firearms use include a physical exertion component as well as tactical repositioning and communication. This should be supplemented with practice, scenario based, dynamic training and evolving risk assessment. They should include reminders of the firearms capability, even beyond qualification distances.

6.3 It is recommended that training material be made available concerning the difference between cover and concealment, including examples of the penetrative capabilities of bullets from various firearms.

After the shooting began, several members involved responded tactically in a manner consistent with their IARD training; ***** working as an independent unit to accomplish this goal.

*****.

This may have hampered members' tactical effectiveness in tracking the shooter through an urban neighbourhood.

6.4 It is recommended that IARD training be adapted to include various environments ***** as well as decision making, planning, communication, asset management, and supervision components to ensure members work through constant risk assessments and that OCC training in coordination/response to high risk incidents should be conducted at the same time as IARD training to emphasize the realism of the scenario.

Although IARD is the current standard, when RCMP training for tactical situations is split into various training modules it artificially compartmentalizes responses to situations and creates challenges around timeframes for re-certification. Training for RCMP members should use realistic scenarios so that there is an emotional and psychological element to the exercise. This way training triggers and creates connections between the various aspects. As an example, if members are required to relay information over the radio to a supervisor after a particularly stressful and physically demanding scenario, it improves their understanding of the importance of using plain language. Training of members in re-engagement of a suspect, resetting a compromised perimeter, proper tactical positioning and movement post-shooting would help prepare them to effectively deal with an incident such as this one.

It should be noted "J" Division is currently utilizing a block training system for their tactical training. During Block training candidates recertify, or qualify in a variety of use of force options. It includes IMIM training, CEW training, IARD training and will soon include carbine training. "J" Division Training Section has also commenced the process of combining the lectures and practical scenarios from each of these options in an effort to optimize their time with each member and increase the opportunities for decision making. This type of training should be the basis of a movement toward one integrated Operational Readiness training scheme. This training should include options created for detachments and districts to further enhance the learning outside of yearly requirements. E-learning and table top exercises where participants are thrust into life-like scenarios using video and audio should be explored for use when candidates are at their home units. RCMP Training sections have already implemented some lessons from this incident to modify how they conduct their tactical training. The 2014 version of "J" Division's block training will include a session based around tactical movement in an urban outdoor environment. Tactical Training Section in Ottawa has also proposed the introduction of decision making at the beginning of scenarios in IARD and a tactical reminder section being built into the lectures on the ***** tactical principles, the ***** tactical errors and the 4 Cs of high stress situations.

One of the factors that is a concern and must be addressed is the failure to ensure that all active members participate in the annual firearms qualification. Some of the 24 RCMP members who initially responded to the incident were not currently qualified on the firearm they were carrying. *****.

Operational Manual; 4.2.5.3 states, 'a Commander can make an informed decision as to whether a member who has failed to meet the minimum standard should have his/her duty restricted pending a retraining session'.

This policy technically allows a Unit Commander to decide whether a member can remain active for duty without qualifying. The realities of the RCMP are such that geography or other circumstances can impact the ability of members to receive timely training. However, the risk assessment to continue permitting non-qualified members to be on active duty should be examined. Notwithstanding the need to advance the standard from one of 'qualification' to one of training, the RCMP must make every effort to adhere to current policy. The number of members who were permitted to carry firearms with expired qualifications is not acceptable.

Section 7: Operational Communications

Question from the Commissioner: How was the communication between members, supervisors, ERT and other coordinated response teams? How was the radio operability?

Operational radio-based communications, including voice and data, played a critical role in the evolution and resolution of this incident. An analysis of the operational and technical capabilities in place between members, supervisors, ERT and other coordinated response teams is necessary because they were the mechanisms that provided situational information and conveyed direction to members. Without direct one on one communication, radio-based communication became the mechanism of command and control and was a fundamental tool to implement all other aspects of the response, including safety, tactics, supervision and logistics. Generally, all radio-based communication, dispatch and locating technology are operationally managed by the OCC which is responsible for:

Status of officers working and on call;

Complaint taking and dispatching;

Operational support to officers on duty;

Liaison between police officers, agencies, and the public.

Additional independent radio systems were used by specialized units, such as ERT, however, these systems were not managed by the OCC.

Although the radio and data communications system in place within Moncton has challenges (which will be explained further in this section of the report), radio discipline as well as the lack of clear and concise broadcasting of information by the members was more of an issue than the technology. This issue is discussed in more detail under the analysis of supervision, with appropriate observations and recommendations.

Operational Communications Centers and Radio Systems

"J" Division operates two distinct and separate OCCs, one in the "J" Division HQ in Fredericton, NB that services all RCMP units and detachments, except for Codiac detachment and the second supporting only Codiac detachment. The latter is a municipal service that caters to both Codiac RCMP and the Fire Service for the communities of Riverview, Dieppe and Moncton. The Codiac OCC consists of two dedicated 911 call takers, one dedicated fire dispatcher and an assistant dispatcher. There is also one dedicated RCMP dispatcher along with an assistant dispatcher for a total of six staff working any given shift. The main RCMP dispatcher communicates with RCMP members via the single live monitored radio channel. The assistant dispatcher picks up the overflow from the main dispatcher. The dispatchers do not speak directly to the telephone caller. All communications to the OCC are voice activated, not 'Request To Talk' (RTT). With RTT a member keys the microphone and is automatically identified and then the OCC calls them to determine what assistance they require. Automatic Numeric Identification (ANI) allows for the member to be immediately identified once they key the microphone. It is notable that the Codiac radio system does not have this feature and therefore the dispatcher has no ability to determine which user is broadcasting unless the member identifies him/herself or the dispatcher recognizes the voice. The lack of ANI creates a critical challenge in identifying a member who may be in need of assistance. During the shooting there were occasions where members keyed the microphone but could not be understood. With ANI the OCC would at least have known who was trying to call.

7.1 It is recommended that Codiac OCC consider the implementation of an automatic numeric identification (ANI) system to support officer safety.

Technical evaluation of Codiac Detachment Radio System

A technical evaluation of the radio coverage determined the signal strength and spread within the city of Moncton are very good. The radio repeater site ***** provides excellent coverage in the core of the Codiac detachment area. There are no notable coverage issues within the Moncton center area, *****. The geographic area where the incident occurred has excellent coverage both for mobile and portable radios.

Communication reception issues do exist outside the city of Moncton, such as *****. Although reception was not an issue in this case, had this incident occurred in another part of the detachment area, it may have been.

7.2 It is recommended that Codiac detachment radio coverage be examined outside of Moncton center to rectify areas that have gaps in coverage.

The system in place in Codiac allows users to 'over talk' other transmissions. This has advantages and disadvantages. Radio systems that prevent over talking can pose officer safety issues such as preventing an emergency transmission while another person is talking. The negative aspect of the "over talk" system is that broadcasts by multiple members at one time can be garbled and impossible to decipher. Both situations occurred on the evening of June 4. The review team was able to listen to broadcasts that would not have been possible if only one member could talk at a time but critical transmissions were inaudible due to more than one member trying to use the radio at the same time. This resulted in the loss of valuable information. For example, a member was able to interrupt radio transmissions with the statement, "clear the air" when he needed air time at a critical moment. However, when someone keyed up a portable radio on UHF when a police car radio was being keyed up the system had no way of prioritizing the audio, so the OCC will receive garbled audio. This occurred repeatedly during this incident.

Codiac detachment general duty radio communications are not encrypted. They are analogue transmission only on the UHF and VHF frequencies and this is the case for all of "J" Division. Some capability exists for specialised units to use encrypted radios that function on a different radio infrastructure. The availability and use of these systems is limited and not available for general duty use and also lacks monitoring by the OCC. They are primarily used by plain clothes units for surveillance.

Unencrypted radio transmissions were a concern for members and the OCC on June 4. They both felt they could not relay some important and specific information by radio for fear the accused and "news chasers" were monitoring transmissions. This placed the safety of responders and the public at risk. The increase in the criminal element using technology to monitor law enforcement channels is a modern reality *****. The lack of using clear, plain language, which would have greatly assisted in developing risk assessments, can be directly attributed to the desire of the members and OCC to not have critical information intercepted by members of the public and the suspect.

There are currently only three contract policing divisions that have encrypted radios for uniformed patrol members. Beyond the type of problems noted above, the lack of encryption creates privacy concerns.

7.3 It is recommended the RCMP examine the implementation of encrypted radio systems for operational effectiveness, officer safety and protection of privacy.

Codiac detachment has two radio towers and frequencies; however, only one was used. This proved problematic due to the volume of radio communications and users competing for air time on a single channel. With 24 members involved in the initial response, the supervisor at the detachment and the OCC operators all utilizing one channel, the system quickly became overloaded. Having users on different channels, based on roles, would have been more effective in managing radio communications and allowed dispatchers more control of the network. For instance, perimeter members could have been on one channel and responders on another. Some geographic locations are better served with increased coverage by the secondary repeater site. This site could be linked, creating one homogenous network, monitored by the OCC through a single radio console using the two repeaters. This would provide improved radio coverage.

7.4 It is recommended that the two Moncton radio repeater sites be permanently patched to ensure members have optimum radio coverage while maintaining communication with the OCC.

Many Divisions have a communications system established utilising primary and secondary channels, one for emergency communications and the latter for non-urgent communications, such as signing in to the system and member to member communications. Some provinces have "mutual aid" channels where other first response agencies, such as Emergency Health Services (EHS) and other police agencies can communicate on a common radio channel. This is not the system that exists in "J" Division or Codiac detachment. Moncton has hosted many large scale events, such as concerts attracting thousands of people. There is a potential for challenges in these situations where a rapid deployment of a large number of members could be required.

7.5 It is recommended that primary and secondary channels be examined in greater detail, to allow dispatchers better control of network airtime.

There is no user guide available to members that outlines radio repeater locations and channel configurations. As a result, some units arriving from outside of Codiac did not know what channel to use and what the geographic boundaries were for the various channels.

7.6 It is recommended that policy be developed that mandates the creation of a radio user guide which will be available to all members. This should incorporate a map of the province showing repeater sites/detachments and a list of the radio channels.

The Codiac detachment VHF mobile radios have ***** functionality, allowing members to listen to several channels at one time. *****, the radio rolls through the preprogrammed channels listening for activity and will stop on an active channel. It is common for the mobile radios to be programmed with adjacent VHF sites *****, so users are aware of what is happening on the radio in a neighbouring patrol area. If the radio is in the ***** mode and the user keys up the mic, the radio will automatically revert to a predetermined 'home' channel. This has the potential to cause radio confusion if a user thinks they are broadcasting on one channel but is actually transmitting on a different channel that may be out of range. There is no formal radio training package for users and there is no user guide provided to members on basic radio operations.

Interoperability Issues

*****

"Technological inter-operability continues to be a barrier to a closer working relationship between Fredericton and Codiac OCCs. Management and supervision of each respective OCC has proven challenging with different models being employed at each OCC over the years."

Interoperability between the Fredericton and Codiac OCCs should be established so that each has situational awareness of events in the other respective jurisdiction. This relates to both radio communication and police vehicle position data.

Cst. Goguen was responding from a neighbouring District and drove directly into gunfire without knowing that the gunman was on the street she was directed to. Cst. Goguen was advised to attend via a call she received on the Fredericton channel. *****. Countless other issues arose as a result of non-Codiac vehicles not being monitored by the Codiac OCC.

In 2007-08, discussions were held regarding a Maritime Radio Communications initiative that would create one radio system that all emergency responders in the Maritime provinces could use. Studies were conducted and the idea was supported at many levels, however, provincial funding challenges prevented implementation. Without this system, there was no radio communication possible for those members who arrived from neighbouring Divisions unless they were able to secure a "J" Division portable radio or pair up with a "J" Division member. As these workarounds were not in place immediately, responders from other divisions could have unknowingly driven into the "hot zone." *****.

The Computer Integrated Information Dispatch System (CIIDS) is designed to maintain officer safety by way of status, mapping, *****, integration with CPIC, PROS and PIP, timers and internal messaging. Codiac's system is limited to its own cars *****. In this case members from "H" Division and "L" Division could not be monitored by the Codiac OCC when they arrived, exacerbating a dangerous situation. The members had to rely on their home Division OCC, which did not have situational awareness and could not contact the Codiac OCC due to the overload on its telephone and radio systems. Other Maritime Divisional OCCs struggled to contact their members to obtain a status check at ***** intervals on members' cell phones that had dying batteries and intermittent capability due to heavy traffic on the overloaded cellular networks.

With the upcoming CIIDS 9 version, there will be an ability to create a Regional agency, in which "H", "J" and "L" could operate as they do today, but in the event of a regional incident, could easily transfer resources (patrol units) across OCC areas of responsibility. Units crossing divisional borders could be assigned to different OCCs, and members would have vital links to officer safety information. OCCs could see and communicate file information with units responding to large scale incidents. Members would be able to maintain status keeping with the OCC of jurisdiction.

7.7 It is recommended that a system be developed, both radio and data, that would allow for communication between RCMP members from the Maritime Divisions, when required to work outside of their home jurisdiction.

CIIDS Mapping and Situational Awareness

A significant issue in directing resources was the lack of adequate mapping within CIIDS, which is used by both the OCC and the Operations NCO. Current CIIDS mapping is not adequate, with free web-based systems providing better terrain imagery than CIIDS mapping. The lack of terrain features did not allow the OCC and Supervisors to optimally plan and implement. The photo below depicts CIIDS mapping for this crime scene, as well as a secure web-mapping service from the NOC, available to DEOC's, through the Infoweb. The web-mapping service would have created a significant advantage to the OCC and Operations NCO during this incident.

CIIDS map viewer used by OCC and Operations NCO. Web map viewer used by NOC, available via the Infoweb.

The OCC, Operations NCO, CIC and DEOC should have been able to share positional data, such a perimeters and other relevant information. The unit that manages this service, the Geospatial Intelligence Section, consists of one member in Ottawa who has an operational and policy role. Not having adequate capacity, or the mandate to deploy this resource to the RCMP as a whole creates a gap. ***** ; however, it requires resource investment and technical interactivity with other RCMP systems.

7.8 It is recommended a high resolution mapping system, such as the web-mapping service from the NOC, be integrated within CIIDS, having the ability to share such vital information as perimeters and location data.

*****

Codiac OCC Call Takers and Dispatchers

*****, a municipal employee, was the primary dispatcher and person who coordinated the initial perimeter. This was implemented in a very effective manner. Needless to say, the flow and intensity of the information that flooded the OCC as this incident unfolded was beyond what could be expected of one person.

There was an Operations NCO working in Codiac detachment, who was actively engaged in calling in members and arranging for services. However, ***** was the single person with direct communication with the frontline members and had the best appreciation of new information coming in. She also was coordinating both with the CIIDS mapping system. The OCC did not have a supervisor working and no regular member was on site within the OCC to assist. The telephone systems were overloaded so that only 911 calls were being answered.

7.10 It is recommended that OCCs should have an experienced NCO available to coordinate operations in critical incidents and to offer direct operational advice to call takers and dispatchers.

All of the employees working in the OCC for that first hour experienced an unprecedented level of activity and information.

*****. It is imperative that the Codiac OCC receive the training provided to other OCCs and that national procedures are in place. While Fredericton OCC is a direct report to the "J" Division Support Services Officer, Codiac OCC is not and reports to the OIC of Codiac detachment.

7.11 It is recommended the reporting structure of Codiac OCC is refined to ensure the Support Services Officer is engaged in the provision of training, equipment and policy considerations.

Emergency Response Team Communications

ERT resources were provided with their own dedicated encrypted UHF repeater. This system is set up and maintained by a radio technician who deploys with the ERT. Any radio issues during this incident were therefore deemed procedural and not related to hardware. (procedural issues are discussed in Section 4, The Evolving Response). Teams from other police agencies and Divisions were provided "J" Division radios, however, the first two "J" Division ERT members on scene were carrying portable radios that were not yet encryption key-coded for the month of June and, as a result they could not communicate with other ERT members.

The communications with aerial surveillance were at times problematic because the General Duty members in the aircraft were not accustomed to ERT communications protocols.

7.12 It is recommended that ERT develop a quick reference guide for non-ERT trained members who may be called upon to offer assistance (e.g. aerial spotters and other observation posts). These reference guides could be provided by the ERT telecommunications technician who would be in a position to instruct members on ERT radio protocols.

Business Continuity Planning, Bilingual OCC Operators

On the evening of June 4, 2014, the National Policy Centre for OCC was advised by "J" Division that the staff of Codiac OCC would require relief as soon as possible for at least two weeks to allow time to process what took place. Codiac OCC is a bilingual operation, therefore replacement operators would have to be fluent in both English and French. This proved challenging because bilingual operators across the country are required in their substantive positions. Operators were located, however, not in sufficient quantity to allow adequate rest. Relief OCC employees worked twelve hour shifts and many worked twelve consecutive days in addition to the shifts they had already completed at their home unit, prior to deployment. This is not an acceptable practice.

Radio Protocol

The events of June 4, 2014, clearly demonstrated a need for the use of plain language by members. Transitioning to plain language will require a standard that is consistent and clear. As this situation turned chaotic, radio based communications became an issue due to the communication of unnecessary or irrelevant information.

With multiple members seeking air time simultaneously they were talking over one another and valuable information was lost. As the incident rapidly escalated, there was a lack of clear communication essential to inform risk assessments by members. Situational awareness is paramount in a crisis and it was impeded by lack of clarity in verbal communications and a lack of direction by supervisors to state clearly what was occurring.

Other countries have advanced to using succinct and simple language over their radio systems. Linguistics experts have studied police crisis communications and learned that verbal clarity in initial transmissions and shorter transmissions results in less 'air time' being used and the standardization of terminology improves radio discipline and assists the OCC and supervisors in terms of recording clear information.

Utilizing terms that immediately get to the point such as "Cst. X has been shot by the suspect" as opposed to "officer down" can greatly influence decision making and improve situational awareness. Information on member's positions lacked clarity and prevented other members from making informed risk assessments, in turn hindered the ability for supervisors to manage the incident. Trying to utilize the 10-Code and phonetic alphabet is not effective and can be time consuming and dangerous in crises. A simplistic use of terminology that is concise, yet descriptive is necessary to ensure critically important information gets relayed to those who need it. Encryption of course, makes this even more effective and safe.

7.13 It is recommended the RCMP create policy that allows for the use of plain language as an alternative to 10-codes in urgent situations.

Section 8: Communications/Media

Question from the Commissioner was to review: How did the media communications unfold? What role did social media play? Was there room for improvement?

To answer the Commissioner's question, the Review Team required input from both National Communications Services (NCS) and "J" Division Strategic Communications in order to capture the local and national scope of this communications challenge.

This section begins with the observations of "J" Division Strategic Communications relating to external and internal communications associated with the shootings in Moncton. It provides insight into the types of communications material created by the section, the communications channels used to distribute the information, and recommendations. This section takes into account the period from June 4 to June 15, 2014.

At the time of this incident, "J" Division Strategic Communications had a complement of seven:

Director of Strategic Communications;

One acting Media Relations Officer (MRO);

One Communications Strategist based in Moncton;

One Communications Strategist in Fredericton;

One New Media/web position;

Two contract employees (one term and one casual).

During the incident, the new media resource was unavailable as this individual is an equipment manager for the ERT and was called out in that capacity for the first 29 hours. A number of resources were unavailable due to personal circumstances. *****.

With the New Media resource working with ERT, "J" Division Strategic Communications did not have a web resource available. As such, these duties were performed by others in the unit, or in a few cases, provided by Ottawa.

Additional resources were deployed from NCS including one MRO and one Communications Strategist who arrived the day after the shooting. The MRO returned to Ottawa on June 10, the day after the funeral and the strategist returned to Ottawa on Sunday June 8, but was replaced the same day with another national strategist who remained in Moncton until June 16. On Monday June 9 the Director of Strategic Communications from NCS was deployed to provide additional support for funeral preparations and serve as the liaison with National Headquarters (NHQ).

Two resources from "H" Division also deployed to "J" Division to assist. A Communications Advisor and MRO arrived the morning after the shooting and returned to Nova Scotia following the news conference on June 6 announcing that the shooter had been captured.

The immediate deployment of resources from Ottawa was helpful, but there was difficulty in securing long term relief for "J" Division staff. The incident required around-the-clock communications support for the first 29 hours. In the following days, with resources tasked to the funeral committee, the core communications team was reduced to handle communications specifically for the incident and ongoing investigation. There was concern staff could burn-out if the incident had continued for several days.

Post-funeral, efforts were made to secure relief for "J" Division communications staff. The NCS strategist remained in "J" Division and media calls were directed to NHQ to relieve some of the call volume. Sufficient relief resources were not identified to cover off in "J" Division. This is seen as a gap, as contingency planning should better anticipate the need for greater relief for a longer period of time post- event. To ensure this does not happen again, the "J" Division Director has spoken with other Division communication sections (notably "E" and "H" Divisions) to explore additional options if a similar situation were to arise, so that relief may be available in the future.

8.1 It is recommended that NCS create a plan that can be referenced to allow relief for Division communications staff in the event of a prolonged incident. The plan should be developed to take into consideration the requirements of each Division.

The communications goal for "J" Division Strategic Communications is, "using communications to assist operations in order to solve and prevent crime." This was the guiding principle in handling communications throughout the incident. To achieve this, the primary focus was establishing the messaging the community required in order to assist the frontline. Factors considered were: What information did residents need so they could be safe? What information can be provided to keep police officers safe? What information can be provided to assist the RCMP catching the shooter? What information will prevent further deaths or injuries? This guided communications for the initial 10 days. Communications were strategic to address issues observed in both the tone of posts on social media or traditional media reporting. This allowed the RCMP to control the message and become the preferred source for accurate information for media and the public. Many comments on social media acknowledged that people were waiting for information to come directly from the RCMP before they would believe/endorse information on social media.

It must be noted that in "J" Division, the Director of Strategic Communications first became aware of this incident from the media and the Moncton strategist learned of the incident through social media. A message was left on the home phone of the Codiac MRO but nothing more was done to attempt to make contact with him. It is critically important that communications personnel be contacted immediately in a situation of this nature.

8.2 It is recommended that standard operating procedures be developed to ensure communications personnel are part of the initial operational callout procedure for serious events.

Given the timing of the incident, approximately 19:20 on June 4, traditional media was not the immediate channel to get information to the public. The radio stations in Moncton had either switched to national programming or were automated (meaning the broadcast was pre-recorded). The daily newspaper would not be out until the following morning and their online service is subscriber based, meaning it was not freely accessible to the general public. The television evening news was over for the day and the next local TV broadcast was not for another three to four hours. This meant that social media was the quickest and most effective way to reach people in the shortest period of time. Given the seriousness of the incident, it was anticipated the information would be shared rapidly and to a wide audience. That was exactly what happened with followers to the RCMPNB and GRCNB feeds on Twitter and Facebook climbing at a staggering rate during the incident. Fortunately, "J" Division has been using social media for the past five years and had built an audience. The Strategic Communications team has experience using social media in a variety of incidents and knew the potential it had in reaching a wide audience.

It is recognized that social media (Twitter and Facebook) is being utilized by RCMP Communications sections on a regular basis. In this case it was extremely valuable when used in conjunction with news releases, news conferences and media availabilities as ways to communicate directly to the public. It helped build credibility and maintained the organization's reputation as an accurate and authoritative source for information during this crisis.

How did Media Communications Unfold?

The Codiac MRO and the communications strategist in Moncton were the two communications resources working out of Codiac for the first 12 hours of the incident. The "J" Division Director worked out of the Fredericton Headquarters monitoring communications needs, providing oversight and liaising with NCS. As previously stated, four additional resources arrived in Moncton. Two NHQ resources arrived in Fredericton on June 5.

It was determined early that one strategist from communications would work with the Incident Commander to expedite approvals. To assist the Incident Commander in the approval process for RCMP Twitter messages, the strategist presented completed Tweets for approval and requested permission to post to social media.

Social media sites were deluged with posts and photographs depicting blood around a vehicle, the shooter in addition to a video of one of the officers being shot. It was important for the RCMP to state the obvious, and in this case, it was information that many in the residential area would have seen. The initial tweets stated that there was an active shooter in a residential neighbourhood and that residents were to stay in their homes and others needed to stay away. This information was fluid as the shooter was actively moving about and required several updates. Once the number of officers shot and killed was confirmed, that information was then communicated. This was important, as there was fear that citizens had been shot because not all of the members who were shot and killed were in police uniform.

Social media became the primary method to communicate directly to the citizens of Moncton but also was a means to communicate directly to media/reporters. The number of calls to the Codiac and "J" Division media relations phones was overwhelming and constant. It was impossible to call back every reporter due to the volume of calls. An attempt was made to issue a new message via social media every 30 minutes to ensure those watching social media would receive timely updates.

Having a continuous presence on social media during this crisis ensured accurate information was disseminated in a timely manner so as to counter any rumours or misinformation. It also acted as a calming tool, so that the heightened fear in the community did not escalate and affect public safety and security. Providing messages with a "call to action" that asked the public to engage allowed them to participate without interfering with police operations and did not leave them wondering what they could do.

A media availability session was held at 00:30 on June 5, by the Codiac MRO who was joined by the Mayor of Moncton at Moncton City Hall. During this availability, most of the information was a repeat of what was being provided through social media. This media event lacked the appropriate setup in terms of podium, flags and backdrop. In the future, Strategic Communications should reassess the need to do this type of availability. NCS should consider issuing a standard deployment kit containing materials required for a news conference.

On the Thursday morning after the shooting at approximately 11:00, the first of many situational updates to the media were held. "J" Division was able to secure space at a local downtown hotel as the venue. The first update included the "J" Division Commanding Officer (CO), Officer in Charge (OIC) of Codiac, Mayor of Moncton, and Premier of New Brunswick. The Premier was a last minute addition to the speaker's lineup at his request.

Additional situational updates were held June 5 at 16:30 and June 6 at 08:00. Both of these updates were RCMP exclusive.

The news conferences did not have a spokesperson addressing the operational side of the investigation. Given the type of incident, this should not be left to the CO or OIC to address as they were providing information about the members who were killed and injured as well as addressing the emotional impact on the Force and the community. Having an operational spokesperson at the news conference would have greatly assisted. It should be noted that information from DEOC was limited and this hampered the ability of Communications to properly prepare a statement regarding the ongoing incident/investigation.

8.3 It is recommended that news conferences in these types of incidents should have a spokesperson presenting the operational perspective of the investigation to reassure the community that police are taking action.

Pre and post meetings with news conference participants were not conducted consistently and should be part of any media component. This allows a communications strategist or MRO to provide advice and ensure participants are comfortable with material prior to the event and then afterwards to provide feedback.

What Role did Social Media Play? Was there Room for Improvement?

Traditional media plays an important role but it is becoming secondary to social media. With Smartphones and handheld devices, the public receives news directly from the source and no longer relies on what traditional media decides is news. This is supported by the number of followers to the RCMPNB account. On the evening of June 4, prior to the shooting, RCMPNB had approximately 18,000 followers on both its English and French accounts on Twitter and Facebook. During the incident, that number grew at an enormous rate, so much so that Twitter nearly shut down the RCMPNB account. Approximately 48 hours after the incident began the number of followers on RCMPNB social media channels reached more than 80,000.

While it was anticipated that media would follow and read the tweets an unexpected result was traditional media posting the tweets on their websites and television broadcasts. Screenshots of the tweets were displayed by media and this was helpful because tweets were used as quotes and attributed to the RCMP without having to physically supply a spokesperson.

Social media is all about engagement. For the RCMP it provides the public with a direct link to their police service and like any two-way conversation, there is some expectation that when a question/comment is posted there will be acknowledgement that it has been received. "J" Division lacked the resources necessary to properly monitor social media. It is important to monitor social media for a variety of reasons including listening to suggestions from the public, monitoring the tone and content of comments, acknowledgement, courtesy and a host of other reasons.

8.4 It is recommended that software solutions be sought by NCS in order to properly monitor social media.

Having the proper hardware to post to social media is also important. While Communications staff can access social media sites on ROSS computers, the sites do not always work smoothly. Instead Strategic Communications uses a standalone computer which is accessed in an office. Hardware goes beyond the desktop equipment, it must also be portable. During the incident in Moncton, communications staff had to use their personal cellular devices to post social media updates because the RCMP issued Blackberry does not permit access to social media sites. NCS has provided laptop/tablet devices but they do not have data capabilities and are heavy and cumbersome. An air card is required to get data, making use of the device challenging and awkward.

8.5 It is recommended that up to date, functional, portable devices be provided to Communications personnel to enable them to effectively use social media and permit them to effectively do their job.

With such a tragic incident, the need for timely internal communications, both nationally and locally was critical. From June 4 to June 13, "J" Division shared or issued 33 general broadcasts on the incident. Coordination of internal communications was acknowledged as a gap in this case. The demands on communications staff to deal with external broadcasts meant there was no single person responsible for internal messages. Communications section was involved in developing messages for the CO and OIC of Codiac but all other general broadcasts were authored by the sender. Liaison with Ottawa was not streamlined on this element and there were National general broadcasts and also Divisional broadcasts being created that had similarities. A single point of contact between Division and NCS may help improve timing and reduce redundancy.

Some, but not all, messages created for the public were also sent internally. This resulted in employees hearing certain information through personal social media accounts or the media. Internal broadcasts that were sent Division-wide via GroupWise email were not necessarily seen by employees from Codiac detachment as they were off duty for a two week period. Another method of communications to reach those employees was required.

The Moncton shooting incident can be broken up into distinct communications components:

Initial incident;

Arrest and subsequent investigation;

Regimental funeral;

Events after the funeral.

Given the magnitude of the regimental funeral, it was important to have a communications person tasked to this committee. However, the tasks assigned to one person were overwhelming given that the organizing committee had just four days to organize a regimental funeral for three fallen members.

The largest component for communications during this stage was coordinating a live broadcast of the funeral. Given all the responsibilities tasked to the sole communications person assigned to the committee, there needed to be two additional communications resources dedicated to the funeral committee. This would allow one person to be present for all briefings and act as a liaison to the committee. The other two individuals would be carrying out tasks. This issue has been brought to the attention of the Corps Sergeant Major who recognizes the need to have a communications person linked directly to the funeral team leader.

The work of coordinating the funeral broadcast on site was eased by using the Chief of the Canadian Parliamentary Press Gallery as the liaison with the national broadcast media. He had the experience and connections necessary to make this happen within a tight time frame. It is necessary to have a communications person as a contact to ensure there is a link to the RCMP and that the needs of the RCMP and broadcast media can be addressed.

8.6 It is recommended that NCS provide a point of contact with the essential skills for regimental funerals (internal or external to the RCMP) who is paired with the Strategic Communications Unit.

Little information was available for the media on site to aid in their broadcasts. Communications staff had the funeral program to distribute, and while a retired RCMP member was lined up to provide live commentary to national television broadcasts, there was a lack of specific RCMP information to provide media on site (traditions and past events where members were killed in the line of duty).

"J" Division does not have an official photographer. This meant that a last minute request prior to the start of the funeral had to be made of the Prime Minister's photographer to capture images for the RCMP.

8.7 It is recommended that all regimental funerals have a professional photographer to ensure they are properly recorded.

While the funeral might be viewed as the end for Communications it was just the completion of another milestone. The investigation was continuing and there was still a heightened nervousness in the community, gifts of condolences needed to be gathered from the property surrounding Codiac Detachment and the RCMP needed to thank the community for its support, all of which required Communications support.

The Strategic Communications unit also offered assistance to the families of the fallen members. In close cooperation with the Staff Relations Representatives, the Communications unit made itself available to the fallen members' families to provide advice on how to deal with the influx of media.

8.8 It is recommended that families of fallen members be made aware that communications assistance is available to act as a buffer between the families and the media. In addition this will provide families access to the RCMP website to post messages/photos.

In the days following the funeral, the communications goal remained the same and that was to assist the frontline with its investigation and to continue to inform the public. This was achieved through messages of thanks from the CO and OIC of Codiac. These messages were posted to social media, in some cases printed verbatim by media, but the authors of those messages did not have to conduct media interviews.

"J" Division has on its website a page titled, "Setting the Record Straight". This page is used when there are gross factual errors in the media, or in this case, rumours and innuendo surrounding the investigation. It was apparent a number of people were offering their opinions to media on what happened on June 4. A message was drafted to advise the public that the investigation was ongoing and to reiterate that the RCMP works with facts, not rumour, and that the RCMP required time to complete the investigation. This message successfully shutdown the rumour mill and had full community support on the RCMPNB feeds.

"J" Division Strategic Communications has been credited with doing an exceptional job throughout this incident but one official acknowledgement came in the form of "The Connected Cops Social Media Event Management Award." This award is given to the law enforcement officer or agency, anywhere in the world, who has used social media to manage and/or influence a public safety/emergency event, whether unforeseen or known. This officer/agency has demonstrated pre-planning and has operated strategically and has successfully implemented social media engagement techniques to positively and effectively communicate public safety information in an urgent or emergency situation. Recently, "J" Division Communications travelled to Great Britain to accept this award in honour of their work on the Moncton shootings.

Role of National Communications Services:

National Communication Services (NCS) and "J" Division Communications were engaged from the first reports of shots fired at officers the evening of June 4. Key communications personnel connected immediately and determined what assistance would be required in "J" Division.

Immediately following the shootings, "J" Division was inundated with calls and requests for live media interviews. NCS MROs assisted to return calls. The morning of June 5, NCS identified an MRO and a communications strategist to send to "J" Division to assist. By June 8, the Division needed more support on the ground, so NCS identified and dispatched a director to attend, as well as a replacement communications strategist. A few days later, media calls to "J" Division were being redirected to NHQ Media Relations staff.

At NHQ, NCS staff involved in supporting "J" Division assumed an operational structure using incident command principles to provide ongoing direction to staff and to disseminate task lists on a regular basis.

NCS employees were engaged in drafting messages for social media for use at NHQ, broadcasts for COs across the country and speeches for the OIC of Codiac. NCS was drafting broadcasts for the Commissioner and preparing media lines for use in NHQ and "J" Division on a variety of subjects along with identifying subject matter experts for commentary during the funeral.

The New Media team at NCS issued regular social media updates and analyses and provided social media and web maintenance support to the Division. From an issues management perspective, the NCS Issues Management community drafted a list of potential issues and worked with policy centres to draft preliminary responses to possible questions. NCS had a conference call with all divisions to inform them of what was happening, provide direction, answer questions and ensure that the RCMP message was consistent. NCS was monitoring "J" Division's Facebook account and posting a memorial banner while "J" Division continued to post new messages.

NCS new media collaborated with Business Solutions, Applications Development, and Application Web Infrastructure, to create an online tool that enabled the public to submit digital photos and video evidence. The material was then processed as part of the ongoing investigation. This tool is a social media advancement that will be presented to Commanding Officers in fall 2014 for their familiarization and future use.

This was the first time the New Media team was tasked with monitoring social media in order to provide an analysis of online activity over a prolonged period of time. The RCMP stays connected with the public via Facebook and Twitter, and the social media reports covered what we were posting from NHQ and J Division accounts, as well as what was being posted and retweeted by others. The analyses also looked at what hashtags were trending on Twitter and who some of the notable influencers on Twitter were.

Twitter dominated the social media platform, with posts related to the shootings, on average, approximately doubling those on Facebook. Media coverage on the shootings was immediate and led to exceptionally extensive social media coverage on an international level.

Below are the numbers of posts across all social media platforms:

146,581 posts between the first reports of gunfire on June 4 to 18:00 June 5;

199,414 posts between 18:00 June 5 and 18:00 June 6;

97,844 posts between 18:00 June 6 and 18:00 June 8;

12,796 posts between 18:00 June 8 and 18:00 June 9;

45,999 posts between 18:00 June 9 and 18:00 June 11;

3,249 posts on June 12 and 13.

8.9 It is recommended that divisions have access to real-time social media monitoring which could help identify operational risks and inform a communications strategy.

Fake social media accounts in the suspect's name were being created almost immediately. Facebook was removing any accounts they could verify as fake.

The media, on the evening of June 4 to morning of June 6 focused primarily on police operations and speculation about the suspect and his motives, while messages of condolences for the fallen members were broadcast on all media throughout the entire period. Traditional media decreased after news of the arrest and the release of the identities of the fallen officers. It increased as many stations aired the funeral, and then decreased again.

Post-funeral, the focus of the coverage changed to questioning if our officers were properly equipped and the ongoing investigation and search for evidence. The new online tool that NCS new media helped create was also a subject of media interest.

It is not possible for the RCMP to communicate internally or externally without translated documents. In order to achieve this in a timely fashion Translation Services must be available 24/7. A Service Level Agreement was signed in September 2014 to address this need.

Section 9: Broader Policy Review

Question from the Commissioner: Were current procedures, tactics and policies followed? Are changes required?

This report has been extensive in its analysis of the tactics and procedures followed during this incident. Where members were complying with, or in contravention, of policy it has been previously mentioned. Where policy was found to be lacking, a comment or recommendation was made within the pertinent section. This section of the report will focus on the changes to RCMP policy that have not already been addressed.

Within the section on Training and Officer Safety Skills there is mention that maintaining and improving firearms proficiency requires practice. This, of course, requires ammunition.

The current policy in relation to members acquiring RCMP ammunition for personal use may hinder members from practicing on their own. Policy provides for practice ammunition being purchased through RCMP Stores, however, there is no requirement for Stores to have extra ammunition on hand for practice. There appears to be a financial disincentive for a Division to provide ammunition because payment for personal practice ammunition must be payable to the Receiver General as opposed to the Division which originally paid for the ammunition.

The availability of ammunition for practice varies greatly across detachments and divisions. At Codiac detachment ammunition was available to some extent for those who wished to do supplemental practice, but its acquisition and dispersal was not through a formal process. The staff at Codiac who control the ammunition were unaware that policy provided for the purchase of practice ammunition.

A Detachment may give ammunition to a member for pistol practice. A free issue of ammunition is made by the Commanding Officer or his delegate through the use of form 1990. Declarations must be made that the member will use the ammunition for proficiency training and that the member has an operational need to be proficient in the pistol. This should be a given. Such a declaration downplays the importance of staying proficient, and can assign a level of shame or blame to the process of asking. Even if a member asks for ammunition in this manner there is no requirement on Stores to purchase extra ammunition so they may or may not have any in stock. There is no corresponding policy in relation to any of the other force firearms.

9.1 It is recommended the RCMP develop an improved system to enable members to obtain ammunition for practice.

Modern defensive shooting competitions are not covered by RCMP policy, however, can be a way for members to enhance their accuracy, speed and overall proficiency with their firearms while dealing with the stress of competition.

9.2 It is recommended the relevant policies and practices should be reviewed to ensure there are appropriate controls and no constraints that would interfere with members improving their firearms proficiency.

Section 10: Firearms Possession by the Accused

Question from the Commissioner: review what, if any, information was known to police as they responded to this call and as the event evolved

Justin Bourque had five non-restricted firearms on June 4 *****. He carried an M305 semi-automatic .308 Winchester (7.62x51mm) rifle with one five round magazine and two prohibited twenty round magazines as well as a 12 gauge pump action shotgun throughout the incident. While Bourque carried the shotgun as a backup throughout the incident, he did not fire it.

He was in possession of at least sixty rounds of .308 Winchester soft point ammunition and 10 rounds of 12 gauge #4 buckshot that were purchased about an hour prior to the incident. Based on the ammunition in his rifle when he was taken into custody, he was also in possession of cartridges containing full metal jacket bullets. When Bourque left his residence he had an additional 17 rifle cartridges and a few shotgun shells, beyond what was purchased that evening. While the .308 Winchester cartridge was developed for military use in the 1950s it has become one of the most common sporting rifle cartridges for long range target shooting and big game hunting. Bullets fired from a .308 Winchester rifle exceed the protective capabilities of soft body armour and Bourque says that he was aware of this fact and that it would take body armour with ceramic plates to stop a .308 bullet. Bourque dropped a box of 20 rifle cartridges at the scene of Cst. Larche's murder, which was almost half of his remaining ammunition for the M305. He did not mention the loss of this ammunition during his interview with police.

*****. The members responding on June 4, 2014, would not have been aware of his identity or what firearms he was in possession of beyond the 911 callers' vague descriptions of long guns. An accurate identification of the firearms in Bourque's possession could have been readily made from the photographs of him that appeared in the media shortly after the shooting.

The M305 rifle Bourque used is a Chinese made semi-automatic version of the American M14 service rifle which was originally adopted in 1959. While there are several model names for the civilian market versions, many colloquially refer to them as "M14s." It is a relatively large and heavy rifle that is popular primarily with target shooters and military firearms collectors. Bourque claims to have known a method of converting this rifle to automatic fire and reportedly attempted to do so, without success. He stated in a post-arrest interview that he didn't pursue conversion to full automatic because he knew it would be uncontrollable and waste ammunition. One of his magazines was specifically manufactured to hold five cartridges and the other two were originally 20 round magazines (the standard size for this rifle) that had been pinned to hold no more than five cartridges, in keeping with Canadian law. It appears that the magazine modifications were removed by Bourque so that the magazines could hold 20 cartridges; turning them into prohibited devices in Canada. Myriad American online sellers of 20 shot magazines offer these for about $20.

*****. Of the three 1940s-50s era infantry rifles that he owned, the M305 would generally be seen as the best one, although he could have readily achieved the same results with any of them. The Remington 870 pump action that he gave away was functionally equivalent to the Mossberg 500 that he chose to carry, with the only of consequence visual difference being due to the Mossberg's ergonomic buttstock.

Whether or not a discretionary prohibition order would have been warranted with the information that could have been shared with police prior to June 4, it is almost a moot point in the Bourque situation. *****. If any of these offences had been reported to police, there would have been an opportunity to launch an investigation which may well have led to the seizure of Bourque's legally acquired firearms, *****.

*****. Changing the criminal code to require the presentation of a valid licence prior to the transfer of ammunition, other than when the ammunition is being used under the immediate supervision of the licence holder, might deter the transfer of ammunition to unlicenced individuals or at least facilitate prosecution of the offense.

Question from the Commissioner: were there reasonable opportunities for law enforcement intervention with the accused prior to his actions? Is there a way to detect early signals from others like the accused?

Justin Bourque's History with Police

The shootings on June 4, 2014, were not Justin Bourque's first contact with the Codiac Regional RCMP. *****.

Intelligence

Prior to June 4, 2014, there were no intelligence holdings which would indicate that Bourque was a potential danger to others. *****.

Open Source Monitoring

The RCMP Tactical Internet Operational Support (TIOS) utilizes the Internet and open source information (OSI) to develop actionable criminal intelligence and generate tangible investigative leads and opportunities that are complementary to traditional policing methods. TIOS supports all of Federal Policing by conducting passive open source Internet research in direct support of criminal investigations. TIOS does not conduct scans of Canadian's online postings outside of specific criminal investigations.

TIOS assisted in this investigation by providing the MCU team with an online profile of the accused *****, identifying witnesses and "police haters" and monitoring online media related to the shootings. TIOS found that Bourque had a small online presence and Facebook was the only social networking account identified. Bourque's Facebook account information was only available upon login and not open to any search engine queries. Bourque had sixty friends listed at the time. Depending on Bourque's privacy settings for these friends they would have had full to limited access to Bourque's Facebook account information. Bourque's timeline had posts about guns, gun control, violence and anti-police sentiment, which were visible to any Facebook user.

*****.

Early Intervention/Prevention

The prevention of crime is often seen solely as the responsibility of the police. Nothing could be further from the truth. The most obvious indications that Bourque might be a danger to society came from observations made by family, friends and acquaintances. Bourque had long been fascinated with firearms and had spent many hours at the range practicing his shooting skills. Recently, he continuously talked about firearms. Once Bourque was identified in media reports, calls were received from associates indicating he'd been expressing anti- authority/anti-police attitudes in recent years. *****, Bourque's father reported similar such language in the days leading up to the shootings. During a conversation on either May 26 or June 2, Bourque told his father he'd had enough with the authorities and that he believed the police were corrupt. He stated he was no longer going to submit himself to the authorities and that the police would never take him to prison.

Others close to Bourque stated they were concerned about his state of mind. At least 60 Facebook "friends" may have seen his postings on his Facebook account. Many were aware of his firearms possession and some knew that he possessed prohibited magazines. *****. Not one reported any of these concerns to a competent authority such as the RCMP or a health care professional. These were all opportunities to intervene early and would have, at the very least, prompted another ***** review. This would have alerted authorities to the fact that ***** and would almost certainly have resulted in a proactive firearms prohibition.

Community Engagement

Police are not the only line of defence for detecting and intervening with individuals who present a possible danger to society. As discussed previously, the typical early signs for such violence are often seen only by those closest to the individual. In addition, information held by the police, if any, will not always be sufficient to conduct a thorough risk assessment. One critical element in improving success in the early identification of these individuals is the engagement of as many members of society as possible. This includes family, friends, co- workers, policing personnel, community service agencies, government departments, health and educational professionals, etc.

"J" Division

J Division is a recognized leader in community engagement and crime prevention having completed the first division-wide roll out of the cutting edge Youth Intervention & Diversion (YID) model. The YID model is an evidence-based process designed to divert youth aged 12- 17 away from the criminal justice system. Utilizing the scientifically validated Risk/Need/Responsivity (RNR) approach to youth crime, YID focuses on screening low risk/no risk youth out of the criminal justice system altogether while referring moderate to high risk youth to community services. The initiative employs validated screening and assessment tools to identify specific risk factors known to cause youth to become involved in crime. Young persons are referred by a police officer to specially trained Youth Intervention & Diversion Teams (YIDT) made up of civilian and uniformed members of the RCMP. The YIDT uses a short version screening tool to screen for risk factors and, as appropriate, refers the youth to a multi-disciplinary Youth Intervention & Diversion Committee (YIDC) made up of community partners such as child social workers, addictions/mental health clinicians, probation officers, educators, and other community service providers. The YIDC completes in-depth, multi-dimensional assessments and conducts case planning, referring youth to appropriate community services based on their individual needs. The end goal is to get the right youth to the right services at the right time while making the most of police and community resources.

Some of the partner agencies making up the multi-disciplinary committees have begun to make use of the committee for youth who have not committed a criminal offence. This increases the number of youth who have access to appropriate screening and enhances the likelihood of intervening early with someone like Bourque who had never been reported to police for having committed a criminal offense. When viewing the various events throughout Bourque's history in isolation, aside from the potential prohibition from firearms, most incidents would likely have resulted in minimal intervention on the part of law enforcement authorities or other professionals. Viewed in aggregate however, especially by a multi-disciplinary team, they would almost certainly have prompted preventative action to address his anger issues and anti-authority attitudes.

A more robust diversion model based on the same principles as YID, and focusing on both youth and adults, has recently been adopted by the NB Department of Public Safety. It will include a mental health screening component and will allow for better transition for youth into adulthood by ensuring available services are consistent. This further increases the likelihood of identifying a young adult like Bourque.

As a result of the success of YID in NB, other divisions are following suit, most notably H, L and B Divisions. YID is also featured in a $25 million national project intended to transform the mental health system for 11-25 year olds in Canada, Transformational Research in Adolescent Mental Health (TRAM).

TRAM – ACCESS Canada

On June 13, 2014, the federal government, through the Canadian Institutes of Health Research (CIHR) announced the launch of ACCESS Canada; a research network developed by TRAM, which is a partnership of CIHR and the Graham Boeckh Foundation (GBF). "J" Division is a principle applicant in the winning ACCESS network and bid with the YID model being a key component in the proposed transformation. The announcement reads, in part:

'ACCESS Canada's goal is to use research evidence to bring about positive change, within five years, to the way we care for young people with mental illness. In Canada, one-in-five people experience a mental illness in their lifetime. However, it is young Canadians that suffer the most, with 75% of mental health problems and illnesses beginning prior to the age of 25, and more than 50% beginning between the ages of 11 and 25. Unfortunately, adolescents and youth have the least access to mental health care, as existing services are designed mostly for younger children and older adults.

ACCESS Canada will seek to close this gap in health care. It will develop strategies to ensure that more young people are connected to the mental health services they need. It will move research evidence to the point of care, to ensure that young people receive the best possible treatments available. Ultimately, ACCESS Canada will improve health outcomes for adolescents and youth by transforming the way mental health care is provided in Canada.'

"J" Division RCMP has co-led this project for NB and has positioned itself as a national leader in the field of youth mental health. The criminal justice system is often the default mechanism for dealing with people with mental health issues. Police officers stand at the front door of that system and both YID and ACCESS provide them with better referral options.

It is important to note that, while Justin Bourque was not found to be suffering from mental illness, we cannot predict what motivating factors or underlying causes might be at the root of the next shooting of this nature. Some individuals who have carried out mass casualty shootings were found to be suffering from mental illness. Furthermore, both the YID and ACCESS projects have mechanisms that allow for someone like Bourque to obtain services. While all youth with anti-authority/anti-social attitudes or anger issues do not necessarily have a mental illness, it is completely appropriate that they would be referred to services within the community and it is quite conceivable that a young person who is displaying some of the same troubling behaviour witnessed by Bourque's family and friends could be referred to services through either YID or ACCESS. The key is that the public must be better educated and engaged and mechanisms must be in place to allow for easy access to services.

Public Education, Early Identification and Easier Access to Services

Both YID and ACCESS seek to increase community capacity and knowledge around youth crime prevention through mental health literacy and to provide mechanisms for easier access to services. The ACCESS project will see six new "safe spaces" created for youth throughout NB to bring mental health services closer to those in need. These spaces will be open to youth experiencing a whole host of issues. To identify another Justin Bourque in the making, it is necessary to screen as many youth and young adults as possible who are experiencing difficulties. The more youth who have access to services, the better chance to intervene early.

Increased awareness can help to reduce the stigma associated with mental illness and can produce a group effect in the general population which has the potential to reduce these types of incidents. In the aftermath of these mass shootings, as in this case, investigations inevitably reveal that there were well intentioned individuals who had information that may have prevented the killings. We often hear that people "didn't think he was serious" or that they "didn't want to interfere." There is often a tendency to avoid over-reacting for fear of someone being labelled. By providing youth-friendly and stigma-free services, ACCESS can assist in overcoming these tendencies to "mind our own business" by removing the labels often assigned to those who need help.

To date, the ACCESS initiative has received formal support from J and H Divisions.

Violence Threat Risk Assessment (VTRA)

J Division has also partnered with school districts in establishing a Violence Threat Risk Assessment (VTRA) protocol. Other RCMP jurisdictions have also embraced this process whereby professionals who work with children, including RCMP employees, are provided VTRA training which is sponsored by local school districts. When a young person is brought to the attention of a school professional due to a potential threat of violence, a multi-disciplinary team comes together to assess the level of threat and develop a plan for intervention. Again, Bourque, having been home schooled, did not come to the attention of any school professionals, nor was his behaviour noted to be an issue during his school-aged years. However, for the majority of children who do attend public schools, VTRA stands as another mechanism designed for the early identification of a potentially violent individual.

J Division is a national leader in establishing best practices in the prevention of crime and early intervention for youth at risk. Engaging the population requires a concerted, multi-disciplinary effort involving a large cross section of government and community partners to educate the public on the warning signs for potential violence. It also requires easy access to intervention services for those individuals who are identified as being in need of help. The TRAM/ACCESS initiative is a government funded project, supported by private sector leaders in mental health research and led by the clinical and research community. It presents a unique opportunity to partner on a national level to benefit youth in need of better mental health services across Canada.

Threats to public safety, no matter the source, need to be taken seriously, especially when the source is an individual known to possess, and possibly obsess over firearms.

11.1 The Review recommends the RCMP consider broadening its support for initiatives that support young people with mental illness.

Criminal Profiling

The RCMP Behavioural Sciences Branch (BSB) routinely does threat assessments for individuals suspected of being on a pathway towards violence. They have several Threat Evaluation Specialists who are required to undergo an intensive understudy program. At the conclusion of their training, specialists use a variety of threat assessment tools to gauge the level of threat an individual poses. They examine various types of threats including school violence, general violence, threats to police members, work place violence, domestic violence and criminal harassment. Specialists also offer strategies and tactics on how to mitigate the threat.

There are several screening tools available for a specialist depending on the type of threat. These tools are not designed for early identification but are used to assess the level of threat a suspect poses towards specific targets. Since Bourque was never reported as a potential threat, there was never an opportunity to engage the expertise at BSB. To be effective, they need to be engaged before the violence occurs.

The Review learned that the capabilities of the BSB are not widely known despite routine lectures at the Canadian Police College and policy which requires threats towards RCMP members to be referred to a Threat Evaluation Specialist. They do several assessments per year on threats toward members and that number is continually growing BSB indicates they are not being utilized to their full potential.

Lone Wolf

Justin Bourque has been described as conducting a lone wolf attack. The term "lone wolf" in this context is defined by the COT Institute for Safety Security and Crisis Management in the Netherlands (Instituut voor Veilgheids – en Crisismanagemt) as a person who engages in criminal activity and who:

Operates individually;

Does not belong to an organized terrorist group or network;

Acts without the direct influence of a leader or hierarchy; and,

Uses tactics and methods conceived and directed by the individual, without any direct outside command or direction.

This definition is consistent with that of other institutions and agencies and is used within the RCMP's National Security program.

The danger of lone extremists has been highlighted in recent RCMP National Security Criminal Threat Assessments. As the Oslo, Norway attacks of July 2011 starkly demonstrate, a motivated individual is capable of planning and successfully inflicting catastrophic harm without prior warning to law enforcement. Incidents involving lone gunmen in the United States and abroad demonstrate the potential lethality and effectiveness of unrehearsed small-arms attacks by individuals with little or no training. Some homegrown violent extremists attack for revenge or notoriety, rather than ideology.

***** that lone offenders using commercial firearms or simply constructed improvised explosive devices (IEDs) against familiar, low security targets, requiring only minimal preparation present clear and present threat, as they do not require an extended planning cycle. As well, lone extremists rarely reveal their specific intentions in advance, providing fewer opportunities for law enforcement to identify them and disrupt attacks before they occur. A lone offender is much more difficult to detect and stop than traditional terrorist cells or groups.

Potential Indicators

Lone offenders come in all forms, ideologies, and operate all over the world. There is no single shared behavioural trait or profile but there are some traits shared amongst many. The following list (used within RCMP Federal Policing) of activities may warrant reporting, and should raise concerns when dealing with individuals:

Many extremists exhibit anti-government, anti-religion, racial prejudice, or disruptive behaviours that will be apparent to those who are in close contact with them.

Various forms of extremist media exist and are often utilized by those wishing to perform terrorist acts. Inspiration and training are often drawn from these sources including books, DVDs, CDs or Internet forums and publications.

Tendency to not to work or socialize well with others. Often these people will live alone, secluded from society. Some may join extremist groups but leave because of conflicts. They may adopt completely new lifestyles and segregate themselves from peer and family groups.

Posting of manifestos of extreme ideology is a high priority for some as they want their message to be heard and made available to the public.

Increased advocacy of violence toward society and government systems often leads to a new acceptance of the use of violence in order to get a point across.

Acquisition of excessive quantities of weapons or explosives materials.

Persistent belief in righting a perceived injustice. They may not only talk about correcting a problem, they may take action by force in hopes of becoming a hero for their cause.

Prior to his rampage how many of these indicators would be applicable in Bourque's case? Bourque did exhibit anti-government and anti-police views. He doesn't appear to have followed extremist media as much as social media from the right of the American political spectrum. The only book at his residence was the US Army Improvised Munitions Handbook. Bourque had difficulty holding a job and had conflicts with a series of supervisors. While he left his family home and saw himself as the black sheep of the family he still had contact with them and he did have a network of friends and was described as sociable. His 'writings' were not a manifesto; instead they consisted primarily of Facebook postings of heavy metal song lyrics and propaganda posters that are typical in anti-gun control and anti- government social media. Bourque's acquisition of firearms took place long before he decided to attack police. He did see himself as fighting what he perceived as injustice.

With respect to the 'pre-event planning' that is frequently cited as an opportunity for law enforcement to learn of impending lone offender attacks, what opportunities may have been missed? Bourque received a large income tax refund in May and used it primarily to pay outstanding bills. Had he been planning a confrontation with police at that time, and used the money to purchase specialized equipment (e.g. body armour) for his mission, it would have made him of interest to police if they were made aware. After the purchase of 70 cartridges, *****. There was no indication of Bourque planning anything specific until late on the afternoon of June 4, therefore there was no planning to detect.

Political Motivation and Ideology

Justin Bourque decided to kill police officers to make a statement about government being too powerful and police being government's enforcers. He wrote about his political views on Facebook and told his friends and family. While he was killing police officers he told civilians that he was only harming, "government officials" and later stated, "bring me more cops." During his post-arrest confession he talked of his political motivation and ideology.

Based on his actions and statements before and during this incident, National Security Enforcement Section (NSES) investigators were engaged. NSES did not find information linking Bourque to extremist groups and did not pursue an investigation of his actions on the night of June 4, within the context of a terrorist act. The "J" Division Major Crime program, with assistance from other Divisions, investigated this incident as a multiple homicide. They laid three charges of First Degree Murder and two charges of Attempted Murder against Justin Bourque.

Even when police have not established pre-existing links to extremist groups, they must also consider examining the individual's actions in conjunction with their political motivations and ideologies.

Section 12: Aftercare of Employees

Question from the Commissioner: Based on the level of care provided after the incident to employees and their families are there any suggestions for improvements?

The shootings in Moncton were a traumatic event that impacted many in a significant way. A traumatic event is described as any event that has sufficient impact to overwhelm the usually effective coping skills of either an individual or a group. These events are typically sudden, emotionally powerful, and outside the range of usual human experience. These events may have a strong emotional effect even on well-trained and experienced individuals.

Very soon after these tragic shootings it was recognized by the management of "J" Division that an immediate response was required to address the needs of employees and their families.

"J" Division Occupational Health Services (OHS) staff and the RCMP National Occupational Health chief psychologist were in Moncton and began to coordinate an immediate response. They attended the hospital to assist the family members. Arrangements were made to bring in local resources along with OHS support staff from "B","H" and "L" Divisions along with peer support personnel, who have extensive experience in the aftercare of employees and their families.

As per the Fallen Members Guide, Staff Relations Representatives (SRRs) from "J","L" and "H" Divisions were brought to Moncton to assist with the fallen members families, the injured members and the families of those who were injured. As outlined in the Fallen Members Guide three members that were close to the fallen members and their families were chosen to be family contacts.

The OIC of Codiac Detachment, Supt. Marlene Snowman, immediately attended the Moncton hospital to visit the wounded and began coordinating the provision of aftercare for the employees and families of Codiac detachment, including the next-of-kin notifications. Due to the rapidly evolving situation and need for security at the scenes it was difficult in the first few hours for Supt. Snowman to get the information she required to make a positive determination on who had been killed. Supt. Snowman waited until she had personal contact with members at the scene before she would confirm anything with the fallen member's families. Family members of the fallen found the delay in confirming the death of their loved ones upsetting. It was later explained the delay resulted from the killer still being at large and crime scenes remaining off limits to medical personnel and most members. These facts made it challenging to confirm with absolute certainty what had taken place. The families understood this explanation.

The following day a team composed of Critical Incident Stress Management (CISM) trained mental health professionals and CISM- trained peer support RCMP employees attended the hospital to assist family members. During this time, they developed a plan to manage the emotional health of employees and families. This team was led by "J" Division Health Services. In additional to immediate one-on-one crisis counseling, they facilitated a continuous series of Critical Incident Stress Debriefings (CISD) and 'psychological first aid' in the days and weeks that followed. The emphasis during a CISD is on mitigating distress, facilitating psychological normalization, providing effective stress management education, identifying external coping resources, and restoring unit cohesion and performance. A CISD is not psychotherapy or counseling but a group support process.

Following the capture of the shooter, senior management provided 14 days of administrative leave immediately to all employees in Codiac. This decision was based on two things; recognizing how the tragedy may affect the mental health of employees and the need to maintain regular policing services as part of the Codiac policing contract. Administrative leave provided time for members who responded to the occurrence to prepare statements and complete notes without interference from general duties. More importantly, it allowed "J" Division an appropriate amount of time to provide mental health care to employees as quickly as possible without adversely affecting the level of policing the community had come to expect. The administrative leave allowed employees to participate in critical incident debriefings, one-on-one counselling, peer support opportunities and time with family without the added pressure of having to report to work at the same time. Senior management saw these as necessary elements to aid the healing of employees to allow Codiac to becoming fully operational as quickly as possible.

Through the RCMP's Health Services and other programs, the after care of employees and families is managed primarily through the philosophy of CISM. CISM is an effective and valuable crisis intervention system designed to mitigate the impact of traumatic incidents on employees and families. These programs are coordinated by the Heath Services Officers of each Division. The range of assessment and treatment options that were and continue to be available to all employees and family members impacted include:

A mandatory assessment of involved members by a licensed Psychologist.

Direct access to Canadian medical and psychological practitioners of their choice, including personal/group/couples/family counseling.

Employee Assistance Services, a short term counseling, assessment and referral service offered under contract by Health Canada. This service is available to spouses and dependents. Two Health Canada clinicians were made available on site for two days.

Professional psychological or medical treatment on an ongoing basis after the incident for effected employees.

To facilitate support, a secure area was made available for the employees and their families to meet with counsellors, peer support personnel and one another. On June 6, 2014, arrangements were made to have Crandall University in Moncton as the support site. The building was ideal for setting up information sessions and Critical Incident Stress Debriefings (CISD) for the employees directly involved in this incident and their families. For security and privacy two regular members were posted at the entrance of the building. This was positively received and was necessary to ensure privacy and to provide a sense of comfort to employees and their families. In the initial days, these services were offered in English only and within days the team offered a bilingual service.

Following the shootings, many members from Divisions across the RCMP came to Moncton to work in a variety of roles, from relief duties in Codiac to assisting with the investigation. Some of them participated in debriefings while in Moncton. Those that didn't have been tracked and are being followed up on by the OHS office in their home Divisions.

The critical stress debriefing centre operated within a complex administrative environment. Participants represented multiple categories of employees and billing was segmented among several insurance providers, creating managerial dilemmas. Group counseling sessions contained all categories of employees and family members and were billed as one service by contractors and cannot be broken down into segments. National direction is required to address how such processes will be managed in the future. Those managing the administration of this should service should be credited for making it work. Many people other than regular members play an important part in the provision of police services and those people must also be supported by a defined after care program. Undue stress is created when those categories of employees or family members are told they are not covered for the services they require.

Municipal employees who were directly impacted by this incident perceived a differentiation in services offered. OCC employees attended the debriefing center the morning after the shootings and their names did not appear on the posted list. This was troubling to them. There were also issues related to sick time for OCC employees in the weeks following that did not impact members. Eventually, this was corrected but prior to that, these employees were subjected to unnecessary stress during an already stressful time. It is recommended that a discussion with municipalities takes place on these issues prior to another crisis occurring. OCC employees must work under the pressure that even the slightest error on their part may potentially be life-threatening for the people they are responsible for assisting. As such, they develop a bond with the members they support and feel a huge burden to keep them safe. They should feel they are equal members of the team.

The "J" Division psychologist provided continual care to the deceased member's families and other non-members affected by this incident. However, this is not a core function of RCMP Health Services and falls outside of the services offered and the staff available.

RCMP Health Services is a program that supports Regular and Civilian members but not families and other categories of employees. Public Service Employees (PSEs), dependents as well as Municipal and contracted services do have insurance coverage for psychological health but it is not the same program and can create a sense of inequality amongst employees. In addition, auxiliary constables, other volunteers and some contracted services have no coverage through the RCMP but they could also be impacted to varying degrees.

Even though no formal system is in place to "top-up" the services available to these categories, where no formal service exists, "J" Division Health Services has been providing some services, where requested. In addition, through the OIC of Codiac, the City of Moncton Human Resource Department arranged similar services through their Employee Assistance Program for all Municipal Employees to match what the RCMP was providing so that those employees were included in the team concept, which is critical in dealing with the emotional toll an event like this can take.

This service was also extended to the Corps of Commissionaires and Codiac Auxiliary Constables, albeit not immediately following this incident. This is an issue that requires further examination at the national level as all municipalities may not react in the same manner nor as quickly.

As the weeks unfolded, Career Development and Resourcing (CDR) personnel met with members who wished a meeting to determine their interest going forward, recognizing that some would seek transfer to other areas of duty upon their return to work. Following those meetings, a committee comprised of CDR, Health Services and the OIC of Codiac met to review findings and prioritize needs, based on an immediate need for a three to five year plan for each member interviewed. This was an important decision and was respectful of employee welfare.

Prior to the return to work date, a town hall was held for the Municipal Employees led by the OIC of Codiac. In attendance were the Union representative, Human Resources and the Mayor of Moncton. On the same day a town hall was held for Regular and Civilian members with the CO, CrOps Officer, OIC Codiac and a number of Commissioned officers as observers. Although emotionally charged, it was necessary and again allowed for a sharing of information and healing.

Once members were ready to return to work, they were screened to ensure they were psychologically ready, taking into account the changes they were to experience at the detachment including working with relief staff they may not have known and many employees no longer present. The screening process was formal and involved an interview with a psychologist.

"J" Division, in collaboration with the contracted NB Operational Stress Injury clinic implemented an effective questionnaire that is sent to all "J" Division members every two weeks and responded to voluntarily. This questionnaire is analyzed to determine changes in members' psychological health from previous questionnaires and quickly acted upon by an occupational health nurse. This is an RCMP OHS service and is not available to Public Service employees, municipal employees or families.

A session was also coordinated for the Codiac members whereby other police officers that had been involved in similar incidents shared their experience. In this instance, the panel was made up of retired police officers from the Moncton police shootings of 1974, active members from Mayerthorpe and Hay River. Approximately 30 Codiac members attended as did the CO of "J" Division. This was reported as being helpful for all in exploring coping strategies.

The overall provision of aftercare for employees and families following this incident was well coordinated and responsive to the needs of RCMP employees and families.

It must be noted this effectiveness was due to the dedication of the people involved who made it work. Both "J" Division Health Services and the Chief Psychologist were on the ground and able to navigate many hurdles that would have been encountered had they not been there. Policies and procedures involving such incidents require further study at the national level to streamline processes, particularly related to the categories of employees and families who require aftercare.

Recommendations

12.1 Development of a national guide to establish roles and responsibilities and advice for managers and persons tasked with implementing an after care strategy. This could include a plan for rapid and scalable deployment plus consideration for long term maintenance to prepare for notable events such as the first year anniversary of the tragedy.

12.2 Updating of the existing Fallen Member guide with considerations for the following: operational briefings of families, possible tour of the fallen members' work space with the family, consideration for the management of flowers, cards and gifts, provision of information on the Depot Memorial and the Peace and Police Officer Memorial in Ottawa.

12.4 Development of a plan for ongoing follow-up at specified periods during the first year and also during periodic health assessments (PHSs) for those members directly involved. Consideration should be given to the utilization of the questionnaire as noted in this section of the review.

12.5 A review of the processes related to the provision of aftercare services to those involved such as families, municipal employees, Auxiliary constables and volunteers should be undertaken.

12.6 Consideration should be given to ensuring that members who are unable to return to work are kept informed of information that could affect them.

12.7 It is recommended that an interview with a psychologist should be conducted with employees prior to their return to duty to prepare them for changes in their work environment that have taken place as a result of a traumatic incident.

12.8 A CISM team, that was not involved with the operation, should provide a Post Action Staff Support (PASS) debriefing for those who conducted debriefings. This should occur once the operation is completed and preferably prior to their return to their home units.

12.9 When an employee is killed on duty certain pay and compensation mechanisms are triggered that generate automated messages and mail to families relating to the cancelation of certain benefits. These automated processes lack sensitivity and cause undue stress. It is recommended a review of these systems be conducted to prevent this from occurring.

12.10 Following the death of a member of the RCMP, there is a substantial amount of required paper work and procedural processes expected of family members. It is recommended that a liaison be identified to assist family members on behalf of the deceased with the completion of all necessary paperwork.

12.11 When a member is physically/psychologically injured or deceased and thus unable to join appointments with their family, the spouses and children of the member cannot access the member's insurance and must rely on private insurance coverage. This coverage can only reimburse the cost of 5 – 7 hours of psychological services per year. It is recommended that steps be taken to rectify this to remove the burden this insufficient funding places on families of the members.

Section 13: Implementation of Mayerthorpe Recommendations

Question from the Commissioner: Are there any recommendations/lessons learned from Mayerthorpe that were particularly relevant to this file?

While initially tasked with examining the extent to which recommendations and lessons learned related to the 2005 murder of four RCMP members in Mayerthorpe, Alberta, the Review Team also examined recommendations stemming from the 2006 murder of two members in Spiritwood, Saskatchewan. The incident in Spiritwood shares key characteristics with what occurred in Moncton, making it particularly pertinent.

Examined reviews include: Fatality Inquiries, Human Resources Skills Development Canada investigation, Hazardous Occurrence Investigation Team (HOIT) reports, and Independent Officer Reviews. The RCMP's national policy centres subsequently reviewed their programs based on all of these reviews' recommendations. This Review examined the extent to which recommendations regarding national policy, training and equipment have been acted upon. Learning from tragedy has to be followed by effectively dealing with identified shortcomings. The Force has an obligation to take actions to protect its members and it must act promptly to do so, not solely for statutory reasons but because of the moral contract it has with the members it sends into harm's way.

Some of the recommendations from the previous incidents were not relevant to the Moncton incident, however, others were and will be outlined below.

Of the Changes made to RCMP policy and training the following apply to Moncton:

General Scene Security

The Mayerthorpe Review completed by Justice Pahl in 2011 recommended, "the RCMP consider the establishment of National Policy guidelines for the securing of potential crime scenes." As a result, the RCMP modified policy on April 23, 2014, in relation to General Scene Security. The Moncton incident had multiple scenes, however, there was no indication members were aware or used the current policy.

Detachment Threat Coordinators

The Mayerthorpe Review completed by Justice Pahl recommended "each detachment should designate a member (as distinct from other employees) to fill the role of Threat Assessment Coordinator (TAC)." The RCMP modified policy in March, 2013. It assigns the responsibility for analysis and maintenance of threat files to the Detachment Crime Analysis Unit, the Detachment Crime Reduction Unit, or the specific member responsible for threat coordination. As has been discussed previously, Justin Bourque would not have been identified using any threat assessment process as he was not brought to the attention of police or mental health professionals by family or friends.

ERT Activation

The Mayerthorpe Independent Officer Review completed by Supt. Head in 2008 recommended, "CCAPS, Critical Incident Program, review national ERT activation/deployment practices and provide direction/ policy to ensure the appropriate service standards are being applied to all jurisdictions." The RCMP modified policy in relation to ERT callouts.

There is a structured process in place for unfolding events whereby the detachment/unit commander/delegate contacts the OCC and the on- call CIC is placed in contact with the requesting detachment/unit. The decision on whether or not to activate the Emergency Response Team will be made by the CIC, based on the discussion with the requesting detachment/unit. Once the decision is made to call out ERT members and any other support it is done via cell phone or pager. As pagers are being phased out, new technology is being implemented to ensure a seamless transition to an equally effective or superior call out system. The call out process is periodically reviewed to ensure the most effective technology is in place to call out CICs, ERTs, CNTs, EMRTs, etc. This incident's ERT callout complied with current policy.

Emergency Medical Response Team

The Mayerthorpe Review completed by Justice Pahl recommended "all Emergency Response Teams should have at least one member with these capabilities." The RCMP subsequently modified policy in relation to emergency medical response in 2011. As of 2013, each ERT has at least one member trained in a three day Tactical Casualty Medic course. This course provides advanced training on techniques such as wound packing, applying tourniquets etc. The on call CIC determines if EMRT is required for a call out. EMRT was attached with ERT in the Moncton incident but did not treat wounded members.

Unintentional Discharge of Firearms

The Mayerthorpe Independent Officer Review recommended, "that CCAPS, Critical Incident Program, develop national policy direction on unintentional discharges of firearms by ERT members during training and operations." There were no changes made as RCMP policy, which has been in place since March 30, 2007, states, "if you intentionally or accidentally discharge a firearm other than that authorized in sec. 2.3. and ch. 4.9.2., immediately report the circumstances to your commander." The RCMP takes unintentional discharges of a firearm very seriously and treats each one as a member involved shooting. As ERT members are bound by this policy, no further policy was developed specific to ERT members. As discussed in the training section above, there was an unintentional discharge of a shotgun during this incident and it was eventually reported and investigated.

Wearing of Uniform

The HOIT into Mayerthorpe recommended direction, similar to "K" Division policy, be developed and introduced nationally. That policy stated, "all members shall wear sidearms when on duty unless they are employed on full time clerical or identification duties. An RM or S/CST. member on plainclothes duty will wear clothing and personal protective equipment deemed appropriate by the commander for such duties. Plain clothes members must have access to all intervention equipment available to members in uniform." The current policy and requirements for Service Order #1 were discussed in the sections of this Review related to equipment and broader policy initiatives. Although this policy was not a factor in the initial call in Moncton, a few members attended scenes and the office without all of their equipment.

Risk Assessment

Justice Pahl's Mayerthorpe Review recommended, "a standardized risk assessment system for high-risk, pre-planned operations be developed." A standardized risk assessment check sheet has been developed and is available to all members in the Operational manual. This check sheet was published as national policy on April 23, 2014. As it was designed for pre-planned events it was not applicable to this incident.

Using Firearms Through Police Vehicle Windows

The Spiritwood investigation into compliance with the Canada Labor Code found the following issue: "As a by-product of the investigation into the shootings of the RCMP Officers in the Spiritwood detachment area on July 7, 2006, it has been determined that there is an inconsistency between the written instructor's firearms training manual, Firearms Training Unit Versions 4 and 6, and the qualified opinion of Training Program Analyst, Basic Firearms Instructor, Sgt. Nick Roy regarding the last option immediate lethal force reaction procedure. *****. The employer shall review the education program regarding situations where a last option immediate lethal force reaction is required when an RCMP Officer is within a vehicle and, if necessary, revise it". As a result, the RCMP modified policy in relation to shooting through police vehicle windows. Curriculum at Depot was changed to account for the totality of the circumstances on a case by case basis when teaching about whether or not this is the proper course of action. Constable Ross fired through his windshield, and he complied with the policy.

Independent Officer Review Template

The Mayerthorpe Independent Officer Review recommended, "CCAPS, Operations Policy Section, develop a nationally standardized Independent Officer Review template with the appropriate links to policy." This recommendation was followed up, but never completed. This review believes that a template would have been helpful as an initial guide, provided it allows for adaptation to deal with the unique features of each incident.

Changes to Equipment

Implementing some recommendations required extensive research and an identified funding model, requiring business cases and senior management approvals for significant equipment purchases. In accordance with Federal Government procurement processes, the business case submissions required sound, defensible data and a demonstration of the best possible service delivery, with consideration for employee wellness and sound financial management. This created obstacles to acquisition and some lengthy delays in providing recommended equipment to frontline employees. This area has been a significant focus for RCMP members and the public, particularly in relation to the lack of carbines and HBA. Many believe that carbines and HBA have taken too long to be delivered to frontline RCMP members. During interviews members have expressed their concerns about these delays and referenced Mayerthorpe and Spiritwood as significant incidents that clearly pointed to the requirement for a longer range weapon and improved ballistic body armour. On June 4, 2014, members of Codiac detachment did not have carbines available to them for general duty.

Body Armour

The HOIT into Mayerthorpe recommended, "members should be given the option to choose to wear a higher level of ballistic protection when they feel the threat warrants it." The Spiritwood Investigation into compliance with the Canada Labor Code also made mention of protective equipment. The RCMP complied with this recommendation and a contract for HBA was issued. The original contract had three options to order 1,000 sets of HBA plates each year after the original contract. There have been some setbacks with the distributor but at the time of this Review, there were approximately 5,000 sets of HBA in the Divisions. On June 4, 2014, the Codiac detachment had ***** HBA in the police vehicles (in some cases still in its original packaging). Codiac's HBA was acquired in 2013. The RCMP had complied with the HBA recommendations. The officer familiarization regarding this vital piece of police equipment was discussed previously. In the situations where ***** it was necessary for the members to decide who would wear the HBA. This should never happen as each member should have access to HBA. Codiac Detachment is in the process of procuring HBA for each member.

RCMP Patrol Carbine

A full examination of the research, procurement and subsequent national rollout of the patrol carbine is beyond the scope of this report. However, it was specifically mentioned by members who responded to this incident, and it was not available to the initial general duty members attending the scene on the evening of June 4. For this reason the Review Team will touch on some aspects of the patrol carbine's development.

Assistant Commissioner (A/Commr) Al MacIntyre was initially assigned to conduct the Independent Officer Review into the Mayerthorpe Incident, a responsibility that was subsequently given to Supt. Tim Head on May 20, 2005. The early recommendations from A/Commr. MacIntyre did not specifically mention the need for approval or acquisition of additional firearms. He did recommend, "that "K" Division, given the growth around the metro Edmonton area, examine the potential for the implementation of an Active Shooter Response Program or ASRP similar to the [Lower Mainland] area of BC."

A/Commr. MacIntyre noted that the ASRP in the Lower Mainland was made up of on duty ERT members who had, "immediate access to heavier long barreled weapons as a result of having an ERT 'light kit' and assault weapon with them at all times". It was further noted that an ASRP, "is an asset that gives long barreled tactical capability much faster and provides an immediate response…pending the call out and arrival of the remaining members of ERT". While A/Commr. MacIntyre's review didn't specifically mention deploying patrol rifles such as the carbine for general duty members, it certainly highlighted the need for a quick and well-armed response to active shooter situations, and is relevant to discussion of this incident. This was an indication that a firearms capability gap existed in the RCMP general duty arsenal. Following this initial Independent Officer report on Mayerthorpe, Csts. Robin Cameron and Marc Bourdages were killed at Spiritwood, by an individual armed with a rifle. On August 29, 2007, an Assurance of Voluntary Compliance (AVC) issued to A/Commr. Darrell McFadyen, then Commanding Officer of "F" Division, (signed on August 30, 2007, with a Compliance Date of October 29, 2007) stated:

"As a by-product of the investigation into the shootings of the RCMP Officers in the Spiritwood detachment area on July 7, 2006, it has been determined that a hazard was present to the retrieval team regarding the suspect's firearm capability in relation to the firearm capability of the officers entering the shooting area, the inability to detect the suspect and the lack of protective equipment available to those Officers. The employer shall complete a hazard assessment of high risk retrieval activities for Officers when ERT response is not present in a timely manner, taking into account, but not limited to the following: types of firearms which may be used by suspects; types of firearms available to officers; types of day-time optical equipment available to officers; types of night-time optical equipment available to officers; bullet resistant equipment which may be required for protection; and, acceptable response times for ERT throughout rural areas. Further, the employer shall take preventative measures to address the assessed hazards as required by the Canada Occupational Health & Safety Regulations 19.5."

Mayerthorpe and Spiritwood occurred against a backdrop of increasingly common active shooter incidents in North America and Europe. The RCMP related incidents and the apparent trend towards more active shootings drew attention to the firearms capability gap that existed within the RCMP frontline and commenced a protracted process of studying, procuring and delivering the patrol carbine to members on the frontline.

In early 2007, senior management of the RCMP were advised by Community Contract and Aboriginal Policing Services (CCAPS) of the need for "evaluating appropriate long barrel weapon systems for the RCMP, in particular the adoption of a semi-auto carbine rifle versus shotgun."

CCAPS also advised, "The current RCMP approved long barreled weapon systems require updating to ensure members are fully equipped to address incidents such as active shooters and other high risk situations involving heavily armed suspects."

By the time Assistance Chief Justice Pahl released his report on the Mayerthorpe Shootings on March 3, 2011, the need for carbines had been identified and the carbine procurement process was underway. The following is an excerpt from his report: "RCMP members should be appropriately armed. The availability of patrol carbines for use by general duty members would increase response capabilities above the current shotgun and pistol deployment. I am satisfied that the RCMP continues to assess and enhance its ability to meet threats which are themselves constantly evolving."

On June 4, 2014, some carbines had been procured by "J" Division and members were taking the carbine certification course. None of the first responders to this incident were trained by the RCMP or had access to a carbine. The ***** carbines procured for Codiac were all assigned to training.

As noted previously it is recognized the RCMP must comply with Federal government procurement processes, conduct research, build business cases and determine funding models before moving to approve and deliver something as significant and costly as a carbine to the frontline. In addition, each Division must seek approval for funding from the Contracting Partners through various means including the Annual Reference Level Update (ARLU). However, the time it took to roll out the carbine project, including the training and delivery of the weapons to members of the RCMP has taken far too long. In October, 2014, there are frontline members of the RCMP who still do not have the training and access to the carbine.

13.1 It is recommended the RCMP take immediate action to expedite deployment of patrol carbines across the Force. This action must include significant and permanent augmentation of the Force's training capacity.

The Canada Labor Code investigation into Spiritwood made the following recommendation in relation to police vehicles:

"As a result of the investigation and analysis into the shootings of the RCMP Officers in the Spiritwood Detachment area on July 7, 2006, it has been determined that bullet resistant materials in the front windshield and front door side glass in the RCMP vehicle could prevent injuries to RCMP Officers. The employer shall complete a hazard assessment regarding gun fire at and around RCMP vehicles including, but not limited to, the following: risks (severity, frequency and duration of hazard exposure) present in different environments and locations such as urban, rural, detachments, regions and divisions; the current protective equipment available and/or utilized by the international law enforcement industry within vehicles including front windshields, front door side glass, front door fixed or portable shields and rear partitions; and, types of gun fire present with correlation to levels of bullet resistant protective equipment requirements. Further, the employer shall take preventive measures to address the assessed hazards as required by the Canada Occupational Health & Safety Regulation 19.5."

To date, the RCMP has done research *****. The National Use of Force unit has, however, recently learned of new, lighter technology which could see bulletproof door panels and or folding ballistic shields added to police vehicles. These options are being studied for potential application.

Additional Recommendations from Mayerthorpe and Spiritwood Previously Discussed in this Review include:

The Canada Labor Code investigation into Spiritwood made the following recommendation which echo comments from this review:

"As a by-product of the investigation into the shootings of the RCMP Officers in the Spiritwood detachment area on July 7, 2006, it has been determined that a system is not present to enable Officers to determine their direction of travel and or location while in RCMP vehicles and be located when emergency response is required for incapacitated Officers. The employer shall complete a hazard assessment regarding the ability for Officers to determine their direction of travel and or location and be located when emergency response is required for incapacitated Officers. Further, the employer shall take preventive measures to address assessed hazards as required by the Canada Occupational Health & Safety Regulation 19.5."

The RCMP has stated they have complied with this request. Mobile Work Station (MWS) capability within the police vehicles, and or training in relation to communication by members with the OCC was deemed sufficient. *****. In addition members on different MWS systems or from different Divisions could not be tracked by the local OCC. *****.

The Hazardous Occurrence Incident report into Mayerthorpe made the following recommendations which echo comments of this Review:

Radio Communications - It is recommended that, when designing future portable radio coverage systems; every effort should be made to expand coverage to allow members, while out of their vehicles, to call for emergency assistance, from wherever they may be in "K" Division.

Requalification Frequency on Firearms - It is recommended that the RCMP encourage members to practice shooting more often and that the RCMP consider means by which the frequency of requalification can be augmented.

13.2 It is recommended the RCMP conduct a thorough analysis of the approval and procurement processes (including the research and development phase) relating to equipment that impacts officer safety. This analysis should include identifying an appropriate senior authority to take responsibility for such projects, establishing appropriately resourced project teams and setting deadlines for delivery.

Recommendations

Everyday members of the RCMP across the country expose themselves to personal risk to protect the communities they serve. They accept the fact that policing is an inherently dangerous profession and every effort should be made to offer them the best protection in terms of equipment, training and support.

I am making the following recommendations to the Commissioner of the RCMP with the hope that the recommendations I put forward in this report will contribute to the safety of the membership and enhance the quality of service that supports all RCMP employees and family members.

Constable Fabrice Gevaudan, Constable Dave Ross and Constable Doug Larche died doing what they truly loved to do. They were known as the RCMP officers you would want responding to your call if you were a citizen who needed help or a member of the RCMP who needed backup. Their desire to protect the public and support their fellow officers resulted in them being quick to respond and place themselves in the way of danger.

Their sacrifice will never be forgotten by their families, Canadians and the Royal Canadian Mounted Police. They truly are heroes.

Within the report, the recommendations are highlighted within their respective section. The following is a complete list of recommendations contained within.

*To clearly understand the context of the recommendation, please refer to the designated section of the report.

1.1 It is recommended that additional training on lethal force over- watch be provided to members.

3.1 It is recommended that members be in possession of a cellular or satellite phone (where available) and police radio while on duty, as a required part of Service order #1.

3.2 It is recommended the RCMP examine how it trains frontline supervisors to exercise command and control during critical incidents.

3.3 It is recommended that the RCMP provide training to better prepare supervisors to manage and supervise throughout a critical incident until a CIC assumes command.

3.4 The RCMP explore options that would allow for a common operating picture (COP) to be available for simultaneous monitoring by frontline supervisors, Critical Incident Command, Division Emergency Operations Center (DEOC) and the National Operations Center (NOC). *****

3.5 That Emergency Management System and the 'web-mapping service from the NOC be considered for each Division and policy, training and supervision be established requiring their use in Critical Incidents, major events and disasters, by DEOC and the CIC.

3.6 It is recommended that, where it does not already exist, each Division establish a policy and protocol through an Emergency Operational Plan to identify entry/exit points and major transportation routes that should be alerted and monitored in the event of a relevant crisis.

4.1 It is recommended that when transporting TAVs long distances it should be done by rail or flatbed truck.

4.2 *****.

4.3 *****.

4.4 It is recommended that annual night training exercises with Air Services be developed and undertaken to maintain proficiency for ERT members.

4.5 It is recommended that infrared (IR) strobes be attached to each TAV to enable them to be identified by specific call-sign during operations with air surveillance.

4.6 It is recommended that non-ERT personnel be selected and trained as drivers for TAVs to free up ERT members for primary duties.

4.7 It is recommended that a standard list of equipment be developed for ERT duties and that this equipment be acquired and distributed across the program.

4.8 It is recommended in large scale events where Air Services is utilized, Air Services personnel with the appropriate training should be assigned to the Command Post as a liaison for air service support.

4.9 *****.

5.1 Policy should be amended to state that where a general duty member is qualified in the use of a long barreled weapon and where one is available; the member must ensure the weapon is in the police vehicle while on duty.

5.2 Firearms must be stored with sufficient ammunition.

5.3 All RCMP members receive a briefing and demonstration on the appropriate deployment of HBA.

5.4 Shotguns should be fitted with slings to enhance their deployment and safety.

5.5 Maintenance and storage procedures of all detachment firearms and ammunition must be the subject of a mandatory ULQA.

6.1 It is recommended that trainers and supervisors take into account how cognitive biases undermine training and consider how to mitigate the effect of these natural and universal thought processes.

6.2 It is recommended that any testing component of RCMP firearms use include a physical exertion component as well as tactical repositioning and communication. This should be supplemented with practice, scenario based, dynamic training and evolving risk assessment. They should include reminders of the firearms capability, even beyond qualification distances.

6.3 It is recommended that training material be made available concerning the difference between cover and concealment, including examples of the penetrative capabilities of bullets from various firearms.

6.4 It is recommended that IARD training be adapted to include various environments ***** as well as decision making, planning, communication, asset management, and supervision components to ensure members work through constant risk assessments and that OCC training in coordination/response to high risk incidents should be conducted at the same time as IARD training to emphasize the realism of the scenario.

7.1 It is recommended that Codiac OCC consider the implementation of an automatic numeric identification (ANI) system to support officer safety.

7.2 It is recommended that Codiac detachment radio coverage be examined outside of Moncton center to rectify areas that have gaps in coverage.

7.3 It is recommended the RCMP examine the implementation of encrypted radio systems for operational effectiveness, officer safety and protection of privacy.

7.4 It is recommended that the two Moncton radio repeater sites be permanently patched to ensure members have optimum radio coverage while maintaining communication with the OCC.

7.5 It is recommended that primary and secondary channels be examined in greater detail, to allow dispatchers better control of network airtime.

7.6 It is recommended that policy be developed that mandates the creation of a radio user guide which will be available to all members. This should incorporate a map of the province showing repeater sites/detachments and a list of the radio channels.

7.7 It is recommended that a system be developed, both radio and data, that would allow for communication between RCMP members from the Maritime Divisions, when required to work outside of their home jurisdiction.

7.8 It is recommended a high resolution mapping system, such as the web-mapping service from the NOC, be integrated within CIIDS, having the ability to share vital information as perimeters and location data.

7.9 *****.

7.10 It is recommended that OCCs should have an experienced NCO available to coordinate operations in critical incidents and to offer direct operational advice to call takers and dispatchers.

7.11 It is recommended the reporting structure of Codiac OCC is refined to ensure the Support Services Officer is engaged in the provision of training, equipment and policy considerations.

7.12 It is recommended that ERT develop a quick reference guide for non-ERT trained members who may be called upon to offer assistance (e.g. aerial spotters and other observation posts). These reference guides could be provided by the ERT telecommunications technician who would be in a position to instruct members on ERT radio protocols.

7.13 It is recommended the RCMP create policy that allows for the use of plain language as an alternative to 10-codes in urgent situations.

8.1 It is recommended that NCS create a plan that can be referenced to allow relief for Division communications staff in the event of a prolonged incident. The plan should be developed to take into consideration the requirements of each Division.

8.2 It is recommended that standard operating procedures be developed to ensure communications personnel are part of the initial operational callout procedure for serious events.

8.3 It is recommended that news conferences in these types of incidents should have a spokesperson presenting the operational perspective of the investigation to reassure the community that police are taking action.

8.4 It is recommended that software solutions be sought by NCS in order to properly monitor social media.

8.5 It is recommended that up to date, functional, portable devices be provided to Communications personnel to enable them to effectively use social media and permit them to effectively do their job.

8.6 It is recommended that NCS provide a point of contact with the essential skills for regimental funerals (internal or external to the RCMP) who is paired with the Strategic Communications Unit.

8.7 It is recommended that all regimental funerals have a professional photographer to ensure they are properly recorded.

8.8 It is recommended that families of fallen members be made aware that communications assistance is available to act as a buffer between the families and the media. In addition this will provide families access to the RCMP website to post messages/photos.

8.9 It is recommended that divisions have access to real-time social media monitoring which could help identify operational risks and inform a communications strategy.

9.1 It is recommended the RCMP develop an improved system to enable members to obtain ammunition for practice.

9.2 It is recommended the relevant policies and practices should be reviewed to ensure there are appropriate controls and no constraints that would interfere with members improving their firearms proficiency.

11.1 The Review recommends the RCMP consider broadening its support for initiatives that support young people with mental illness.

12.1 Development of a national guide to establish roles and responsibilities and advice for managers and persons tasked with implementing an after care strategy. This could include a plan for rapid and scalable deployment plus consideration for long term maintenance to prepare for notable events such as the first year anniversary of the tragedy.

12.2 Updating of the existing Fallen Member guide with considerations for the following: operational briefings of families, possible tour of the fallen members' work space with the family, consideration for the management of flowers, cards and gifts, provision of information on the Depot Memorial and the Peace and Police Officer Memorial in Ottawa.

12.4 Development of a plan for ongoing follow-up at specified periods during the first year and also during periodic health assessments (PHSs) for those members directly involved. Consideration should be given to the utilization of the questionnaire as noted in this section of the review.

12.5 A review of the processes related to the provision of aftercare services to those involved such as families, municipal employees, auxiliary constables and volunteers should be undertaken.

12.6 Consideration should be given to ensuring that members who are unable to return to work are kept informed of information that could affect them.

12.7 It is recommended that an interview with a psychologist should be conducted with employees prior to their return to duty to prepare them for changes in their work environment that have taken place as a result of a traumatic incident.

12.8 A CISM team, which was not involved with the operation, should provide a Post Action Staff Support (PASS) debriefing for those who conducted debriefings. This should occur once the operation is completed and preferably prior to their return to their home units.

12.9 When an employee is killed on duty certain pay and compensation mechanisms are triggered that generate automated messages and mail to families relating to the cancelation of certain benefits. These automated processes lack sensitivity and cause undue stress. It is recommended a review of these systems be conducted to prevent this from occurring.

12.10 Following the death of a member of the RCMP, there is a substantial amount of required paper work and procedural processes expected of family members. It is recommended that a liaison be identified to assist family members on behalf of the deceased with the completion of all necessary paperwork.

12.11 When a member is physically/psychologically injured or deceased and thus unable to join appointments with their family, the spouses and children of the member cannot access the member's insurance and must rely on private insurance coverage. This coverage can only reimburse the cost of 5 to 7 hours of psychological services per year. It is recommended that steps be taken to rectify this to remove the burden this insufficient funding places on families of the members.

13.1 It is recommended the RCMP take immediate action to expedite deployment of patrol carbines across the Force. This action must include significant and permanent augmentation of the Force's training capacity.

13.2 It is recommended the RCMP conduct a thorough analysis of the approval and procurement processes (including the research and development phase) relating to equipment that impacts officer safety. This analysis should include identifying an appropriate senior authority to take responsibility for such projects, establishing appropriately resourced project teams and setting deadlines for delivery.

I am pleased you have accepted the role as Reviewing Officer to examine the events surrounding the murder and attempted murder of the RCMP officers that occurred in Moncton on June 4, 2014. As you know Justin BOURQUE, the lone shooter, has been arrested and criminally charged for the deaths of three members: Cst. David Joseph ROSS, Cst. Fabrice Georges GEVAUDAN and Cst. Douglas James LARCHE. Justin BOURQUE has also been charged for the attempted murders of Cst. Eric Stephane J. DUBOIS and Cst. Marie Darlene GOGUEN during the same incident.

On the evening of June 4, 2014, the Codiac Regional RCMP responded to a call of a suspicious male, armed with rifles, walking around in a residential neighbourhood. As members responded to the scene, they were fired upon by Justin BOURQUE. Justin BOURQUE was later arrested by a combined team of Emergency Response Team members on June 6, 2014.

I am requesting that you conduct an internal review into this incident. Your overall mandate is to conduct a fact finding review into the following areas and if applicable, to provide recommendations:

Tactics and Response to the initial call on June 4, 2014. (Does the manner in which the members were dispatched and coordinated in their response to this call suggest any improvements can be made in RCMP training, policy or other areas? Are there recommended improvements to the tactics employed given the facts known at the time?)

Decision Making and Risk Assessment to the initial call on June 4, 2014. (Was there an opportunity to reassess the call and our response as it unfolded in the early moments?)

Supervision during the entire incident (Does the manner in which this incident was supervised suggest any areas for improvement?)

The Evolving Response (How was the evolving ERT/coordinated response managed?)

Equipment and Weapons (What was the state of availability of equipment and weapons and were they being used?)

Member Training and Officer Safety Skills (Are there any identified gaps in existing training for our members? Are there new training requirements that can reasonably be placed on the RCMP by this event?)

Operational Communications (How was the communication between members, supervisors, ERT and other coordinated response teams? How was the radio operability? )

Communications/Media (How did the media communications unfold? What role did social media play? Was there room for improvement?)

Firearms Possession by Accused (What, if any, information was known to police as they responded to this call and as the event evolved?)

Perpetrator Information/Intelligence (Were there reasonable opportunities for law enforcement intervention with the accused prior to his actions? Is there a way to detect early signals from others like the accused?)

Aftercare of Members and Staff (Based on the level of care provided after the incident to members, staff and their families, are there any suggestions for improvement?)

Implementation of Mayerthorpe Recommendations (Are there any recommendations/lessons learned from Mayerthorpe that were particularly relevant to this file?)

Assistant Commissioner Byron Boucher, Contract and Aboriginal Policing, Ottawa HQ, will be your primary point of contact for this review. You may attend any scene of the incident if you feel it will be of benefit to your review. You may also review the investigation and other documentation, and interview members or witnesses, providing it does not interfere with the criminal investigation nor the ongoing Employment and Social Development Canada Health and Safety Officer (HSO) and the RCMP internal Hazardous Occurrence Investigation Team (HOIT) investigations into the matter. We will work with you to provide additional resources as required.

You will be required to present an interim report within 45 working days from when you commence your review and a concluding report with recommendations within 90 working days of your commencement. Should additional time be required, please make the appropriate arrangements with Assistant Commissioner Boucher.

You will be remunerated as per your contract and reimbursed for your expenses in accordance with applicable policies. My office will be responsible for any costs associated with your review.